Does varicocele grade determine extent of alteration to spermatogenesis in adolescents?

Long-term impact of commonly performed operations in pediatric urology on reproductive and sexual health

Introduction

Sexual dysfunction is highly prevalent among men of reproductive age. Clinical practice guidelines have been established to assist providers in identification and education of patients who are at increased risk for infertility and sexual dysfunction with certain congenital and acquired urogenital disorders. The authors sought to review the reproductive and sexual health implications of treating common childhood urological conditions with commonly performed surgical procedures.

Methods

To ensure the inclusion of influential and highly regarded research, we prioritized citations from the most-frequently cited articles on our respective review topics. Our inclusion criteria considered studies with substantial sample sizes and rigorously designed methodologies. Several topics were reviewed, including penile chordee, hypospadias, posterior urethral valves, varicoceles, undescended testicles, and testicular torsion.

Results

For chordee, surgical plication or corporal grafting may be employed. Erectile function remains unaltered post-surgery, while penile length may decrease after repair, which may be avoided using dermal grafts. Hypospadias repair hinges on severity and availability of the urethral plate. Those who underwent hypospadias repair report decreased penile length, but sexual satisfaction, libido, and semen quality are comparable to controls. Posterior urethral valves are usually treated with valve ablation. While valve ablation and bladder neck incision have not been found to affect ejaculatory function, high degree of concurrent renal dysfunction related to nephrogenic and bladder dysfunction may impact semen parameters and erectile function. Regarding varicocele, earlier management has been associated with better long-term fertility outcomes, and surgical intervention is advisable if there is observable testicular atrophy. Earlier repair of undescended testicle with orchiopexy has been found to improve fertility rates as well as decrease malignancy rates. Unilateral orchiectomy for testicular torsion without the ability for salvage has been shown to have decreased semen parameters but unaffected fertility rates.

Conclusion

Infertility and sexual dysfunction are multivariable entities, with etiologies both congenital and acquired. At the same time, many common pediatric urology surgeries are performed to correct anatomic pathology that may lead to reproductive dysfunction in adulthood. This review highlights the need for diagnosis and management of pediatric urologic conditions as these conditions may impact long-term sexual function post-operatively.

Understanding the impact of varicocele on sperm capacitation

OBJECTIVE

To study the relationship between the seminal sample quality of men with varicocele and sperm capacitation.

DESIGN

Cross-sectional observational study.

SETTING

Academic hospital.

PATIENT(S)

Seventy-six men (19 control and 57 with varicocele) were analyzed.

INTERVENTION(S)

Semen samples were submitted to a discontinuous density gradient for sperm selection. Sperm capacitation was induced using a human tubal fluid medium supplemented with bovine serum albumin.

MAIN OUTCOME MEASURE(S)

After capacitation induction, the sperm were assessed by capacitation state, computer-assisted sperm motility, mitochondrial activity, membrane integrity, acrosome reaction, and intracellular oxidative stress.

RESULT(S)

The capacitation period increased sperm motility, showing an increase in the average path velocity and a decrease in the straightness compared with sperm before capacitation (paired analysis). After capacitation, the rate of capacitated sperm, motility, and mitochondrial activity showed differences between groups (control and varicocele). The varicocele group showed lower mitochondrial activity and capacitation than the control group. On the other hand, no significant differences were observed in the other variables evaluated.

CONCLUSION(S)

Varicocele men showed less viable sperm and mitochondrial activity than control men after capacitation sperm. The induction of capacitation altered motility by increasing path velocity and decreasing straightness in all of the studied groups, evidencing the occurrence of hyperactivation.

Evaluation of oxidative stress in seminal plasma of adolescents with varicocele

Varicocele, defined by a dilation of efferent testicular veins, is the most commonly identifiable, surgically correctable lesion associated with male-factor infertility, starts at puberty and causes a progressive decline in fertility potential. The pathophysiology of infertility caused by this disease is still poorly understood, but it is suggested that the main mechanism is oxidative stress. Therefore, the aim of this study was to verify if the varicocele is associated with changes in enzymatic antioxidant mechanisms and seminal plasma lipid peroxidation levels in adolescents. We recruited 90 adolescents that were divided into control (C; n  = 27); varicocele and normal semen (VNS; n  =46); varicocele and altered semen (VAS; n  =17). Seminal and serum levels of lipid peroxidation were quantified by thiobarbituric acid reactive substances (TBARS). Seminal plasma antioxidant profile was evaluated by the activities of catalase (CAT), glutathione peroxidase (GPx) and superoxide dismutase (SOD). The VAS group had increased lipid peroxidation levels when compared to the other groups. The levels of serum lipid peroxidation and activities of the enzymes SOD and GPx did not differ between groups. CAT was undetectable by the method used. In conclusion, in adolescents with varicocele and altered semen analysis, there is an increase in seminal lipid peroxidation levels compared to adolescents with varicocele and without seminal change and adolescents without evident varicocele. However, the observed oxidative stress is not caused by a decrease in superoxide dismutase and glutathione peroxidase activities, which did not differ between adolescents with and without evident varicocele.

Lay summary

Varicocele, defined by a dilation of efferent testicular veins, is the most commonly identifiable, surgically correctable lesion associated with male-factor infertility, starts at puberty and causes a progressive decline in fertile potential. There is still much that is not understood regarding how exactly it affects semen quality, but most studies agree that oxidative stress, which is defined as excessive amounts of free radicals in relation to antioxidant defense, is an important mechanism. In this study, we aimed to verify if the varicocele is associated with changes in antioxidant defense and semen oxidation in 90 adolescents with and without varicocele. In adolescents with varicocele and abnormal semen, there is an increase in semen oxidation compared to controls or to the group with varicocele and normal semen quality. Our results can help to understand how varicocele leads to infertility in adolescents, identifying changes in oxidative activity in semen, since the onset of varicocele and before damage to sperm production can be detected.

Peak retrograde flow a potential objective management tool to identify young adults with varicocele 'at risk' for a high sperm DNA fragmentation

INTRODUCTION

Determining which patients are negatively affected by varicocele would enable clinicians to better select those men who would benefit most from surgery. Since conventional semen parameters, have been limited in their ability to evaluate the negative effects of varicocele on fertility, specialized laboratory tests have emerged.

OBJECTIVE

To identify clinical and ultrasound parameters (including PRF) which would negatively influence standard and functional semen variables in young adults with a varicocele.

DESIGN

Prospective, cross-sectional observational study.

SETTING

Antwerp University Hospital, Belgium.

PATIENT(S)

Young volunteers between 16 and 26 years, Tanner 5, were recruited.

INTERVENTION(S)

Every participant had a scrotal ultrasound to calculate testicular volumes. If a varicocele was present, the grade, vein diameter, peak retrograde flow (PRF) in supine position and spontaneous reflux in standing position were measured. All participants provided a semen sample. Standard semen parameters were analyzed and sperm DNA fragmentation.

MAIN OUTCOME MEASURE(S)

Of all clinical and ultrasound parameters tested, PRF was an objective tool identifying young adults with a varicocele. PRF was highlighted by the prevalence of SDF, both in the total and vital fractions of the spermatozoa, providing opportunities to manage such 'at-risk' adolescents/young adults.

RESULT(S)

Total SDF was significantly increased in grade 3 varicocele compared to grade 1 and 2 but no significant difference with vital SDF or standard descriptive semen parameters was seen. Total and vital SDF on the other hand were significantly increased when PRF was above 38.4 cm/s. Standard semen analysis showed no difference with PRF as an independent predictor. Testicular atrophy index, varicocele vein diameter and spontaneous reflux revealed no significant differences in both the descriptive and functional semen variables.

DISCUSSION

Descriptive semen parameters showed no significant difference between the non-varicocele controls and the varicocele group with low and high PRF. Increased PRF negatively influenced sperm quality via increased DNA fragmentation both in the total as in the vital fractions of the semen.

CONCLUSION(S)

Of all clinical and ultrasound parameters tested, PRF was an objective non-invasive tool to identify varicocele patients at risk for a high SDF.

Effects of Primary Varicocele and Related Surgery in Male Infertility: A Meta-Analysis

Purpose: To investigate the effect of primary varicocele and related surgery in male infertility through meta-analysis.

Methods: A systematic search of the literature was conducted using the Medline, Embase, Cochrane, and CNKI databases. The search was up to September 2019. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Data were analyzed using RevMan 5.2. A random-effects model was used to calculate the overall combined risk estimates.

Results: After screening 687 articles, 4 randomized controlled trials with 349 patients were included. One hundred seventy two patients were addressed in embolization/ligation, with 177 patient's observation treatment. The number of spontaneous pregnancies in the two groups was 41 and 40, respectively. There was no significant difference in pregnancy rate between the operation group and the control group. RR = 1.05 [0.72, 1.54].

Conclusion: There is not enough evidence to explain the surgical treatment of varicocele can improve the natural fertility of the infertile couples, and there is still a need for most of prospective randomized controlled trials to verify the efficacy of varicocele surgery for treating of male infertility. We do not deny the importance of this operation, we just want to call on everyone to strictly grasp the indications of the operation, avoid ineffective medical expenses, and avoid unnecessary pain to patients.

Laparoscopic treatment of varicocele within adolescents in two African countries

Varicocele is often ignored by adolescents and their parents, in our context. The aim of the study is to present the indications and results of laparoscopic treatment in a population of adolescent students.

SUBJECTS AND METHODS

It is a descriptive and analytical prospective study over a period of 9 months (January to September 2013), focussed on cases of varicocele Grade 3 found in adolescents during a screening, and who underwent surgical treatment by laparoscopy. The laparoscopic treatment was done as part of a training mission to paediatrics surgeons, through a European Non-governmental organisation in two university hospitals in Africa. Of 2724 adolescent students examined, 149 (5.47%) had a varicocele. The average age was 16.39 ± 2.05 years (12 and 19). The side was unilateral (79.19%) with 76.51% left or bilateral (20.81%) (P = 0.00). According to the classification of Dubin and Amelar, there were 58 (38.92%) cases of Grade 1, 66 (44.30%) were Grade 2 and 25 (16.78%) were Grade 3.

RESULTS

The laparoscopic treatment was performed in 23 patients with varicocele Grade 3, by modified Palomo's technique, sectioning a segment of vessels between clips (15) between nodes (2) or after coagulation without clips and ligation (6). The hospital stay was 36 h. It has been observed one case of post-operative moderate vaginal hydrocele and 11 cases testicular hypertrophy.

CONCLUSION

The laparoscopic treatment of varicocele in adolescents reduces post-operative morbidity related to conventional open surgery. This technique has been available in two poor African countries through partnership north-south.

An Infertile Couple's Long and Expensive Path to Varicocele Repair

OBJECTIVE

To characterize the pathways to care that infertile couples requiring varicocele repair (VR) pursue prior to presenting to a male fertility clinic.

METHODS

An IRB-approved single center retrospective review of patients undergoing VR after presentation to an academic male fertility clinic was performed. Patients whose charts included partner histories were assessed for duration of attempting conception, prior workup, and assisted reproductive technology (ART) use.

RESULTS

A total of 405 couples were included. At presentation, mean age was 34.4 (SD ± 6.5) years for men and 31.1 (SD ± 4.3) years for women (P < .0001). A couple's first visit to a physician was a gynecologist in 59% (198/334) of couples, a reproductive endocrinologist (REI) in 25% (83/334) of cases, with 14% (47/334) presenting without a previous female workup and were self-referred, and 2% (6/334) seeing both a gynecologist and REI prior to presentation. On average, couples attempted pregnancy for 22.3 (SD ± 21.1, range 0-120) months prior to presentation. Eighteen percent of couples underwent ART prior to presentation. Couples who had undergone ART had lower pre-VR total motile sperm counts compared to couples not pursuing ART prior to presentation (P = 0.031). The majority (70.4%) of females had no abnormality in their workup, making varicocele the only correctable factor for infertility in the couple.

CONCLUSIONS

Our findings show a significant delay in referral of infertile men requiring VR. Eighteen percent of couples underwent costly ART prior to an inexpensive male workup. In an era of medical cost containment, early referral to a male infertility specialist is imperative.

Association between varicocele grade and semen analysis parameter

Background: Varicocele is a condition characterized by elongation, dilatation and tortuousity of spermatic vein in pampiniform plexus. Approximately 50% of infertility cases among men are caused by varicocele. The varicocele may affect the components of sperm. This study aimed to determine the association between varicocele grade based on ultrasound Doppler examination and sperm concentration, sperm motility, and sperm morphology based on semen analysis examination.Methods: This was a descriptive, cross-sectional study which used secondary data from 85 patients that visited Department of Urology, Cipto Mangunkusumo Hospital, then underwent ultrasonography examination at Department of Radiology, Cipto Mangunkusumo Hospital and semen analysis examination at Department of Obstetrics and Gynecology, Cipto Mangunkusumo General Hospital.Results: Varicocele grade was significantly associated with sperm morphology, concentration and motility (all p<0.05). Significant association was found between maximum condition and semen analysis component.Conclusion: Varicocele grade may affect semen analysis component.

Impact of varicocelectomy on the proteome profile of testicular tissues of rats with varicocele

Varicocele (VC) is a common cause of male infertility, but the molecular mechanisms involved in its pathogenesis are unknown. We investigated the impact of varicocelectomy (VCT) on proteome profiles in testicular tissues of rats with VC, and analysed associated target genes and signalling pathways. Sixty male rats with VC were divided into two groups: control (n = 30), and VCT (n = 30). Tissues were collected 4 weeks after sham or VCT surgery. Matrix-assisted laser desorption/ionisation time-of-flight/time-of-flight mass spectrometry (MALDI-TOF/TOF MS) was used to analyse the comparative proteome profiles. Kyoto Encyclopaedia of Genes and Genomes (KEGG) Orthology-Based Annotation System was used for bioinformatic analysis. Fifteen proteins were differentially expressed between control and VCT groups. These differentially expressed proteins are associated with several specific cellular processes associated with the pathogenesis of testicular growth arrest associated with VC. Furthermore, the evaluation by transmission electron micrograph showed that VCT could decrease apoptosis of spermatogenic cells in rats. Understanding such molecular pathways might provide physicians with a better insight into VC and with potential targets for treatment.

Varicoceles affect semen quality of infertile men in Southern China: A cross-sectional study of 5447 cases

The association of varicoceles with infertility is well established, but the exact effect of varicoceles on semen quality among patients with infertility is still poorly known. The study aimed to examine the prevalence of varicoceles among Chinese men with infertility and to examine the factors associated with semen quality.This was a cross-sectional study of 5447 male patients treated for infertility at the Affiliated Hospital of Guangdong Medical University from October 2012 to December 2015. The patients were divided on the basis of the presence of varicoceles. Examinations of the amount of semen and sperm morphology were performed according to seminal parameter detection methods recommended by the World Health Organization.Patients with varicoceles (n = 1429/5447, 26.2%) were slightly younger (P = .046), and had smaller testis (P = .019), higher frequency of abnormal epididymis (P < .001), slightly shorter infertility duration (P = .046), and lower frequency of smokers (P = .012). There was no difference in the distribution of occupations (P = .777). Using multiple linear regression analysis, varicoceles were shown to be independently associated with semen volume [B = -0.153, 95% confidence interval (95% CI): -0.245 to -0.062, P = .001], sperm concentration (B = 9.633, 95% CI: 7.152-12.114, P < .001), proportion of sperms with normal morphology (B = 0.951, 95% CI: 0.623-1.278, P < .001), motility (B = 3.835, 95% CI: 2.675, 4.995, P < .001), total sperm count (B = 22.481, 95% CI: 13.333-31.629, P < .001), and forward movement sperm count (B = 15.553, 95% CI: 9.777-21.329, P < .001). Varicoceles were present in 26% of Chinese male patients with infertility.Varicoceles were independently associated with sperm volume, sperm concentration, proportion of sperms with normal morphology, motility, total sperm count, and forward movement sperm count.

The Dilemma of Adolescent Varicoceles: Do They Really Have to Be Repaired?

The primary indication for varicocele repair in adults, that of failed paternity, must be substituted in the adolescent population with surrogate parameters of testicular size differential and semen analysis. Making recommendations based on these two parameters is incredibly difficult because studies often have contradictory findings, different patient populations, and lack of long-term follow up of the key endpoint, paternity. Therefore, it is not a surprise that recommendations for adolescent varicocele repair are general (with some exceptions) and necessarily so because of limitations in quality of evidence. Apart from pain, all indications for varicocele repair in adolescence remain controversial. This highlights the most important task for future studies: to prevent pediatric urologists from allowing a potentially damaging process to go untreated, while at the same time avoiding unnecessary intervention on a highly prevalent condition.

The varicocele: diagnostic dilemmas, therapeutic challenges and future perspectives

A varicocele is defined as the abnormal dilation of the internal testicular vein and pampiniform venus plexus within the spermatic cord. If a semen analysis is not obtained from the adolescent male, in the absence of other symptoms, the main clinical indication used by many urologists to recommend repair is testicular atrophy. The varicocele may result in testicular damage in some males causing testicular atrophy with impaired sperm production and decreased Leydig cell function, while in other males the varicocele may seemingly cause no ill effects. In adult men, varicoceles are frequently present and surgically correctable, yet the measurable benefits of surgical repair are slight according to a Cochrane review. While occurring more commonly in infertile men than fertile men, only 20% of men with a documented varicocele will suffer from fertility problems. Most varicoceles found in adolescents are detected during a routine medical examination, and it is difficult to predict which adolescent presenting with a varicocele will ultimately show diminished testicular function in adolescence or adulthood. As in adults, the mainstay of treatment for varicocele in adolescents is surgical correction. However, unlike an adult varicocelectomy (the microsurgical approach is the most common), treatment for an adolescent varicocele is more often laparoscopic. Nevertheless, the goals of treatment are the same in the adolescent and adult patients. Controversy remains as to which patients to treat, when to initiate the treatment, and what type of treatment is the best. This review will present the current understanding of the etiology, diagnosis and treatment of the adolescent varicocele.

Alterations in the proliferative/apoptotic equilibrium in semen of adolescents with varicocele

PURPOSE

To verify if the presence of varicocele (grades II and III) with and without seminal alterations, using the 5^th centile cutoff values in table A1.1 of the World Health Organization (WHO, 2010) manual, alters the seminal plasma levels of proteins DNASE1 (deoxyribonuclease-1) and IGFBP7 (Insulin-like growth factor-binding protein 7), which are related to apoptosis regulation and cell proliferation, respectively, demonstrating that these proteins are important for correct spermatogenesis.

METHODS

This cross sectional study was performed at the Sao Paulo Federal University Paulo between May 2014 and April 2016. A total of 61 male adolescents were included in this study, of which 20 controls without varicocele (C), 22 with varicocele and normal semen analysis (VNS) and 19 with varicocele and altered semen analysis (VAS). Seminal plasma from each patient was used for Western blotting analysis of individual protein levels. Values of each protein were normalized to a testicular housekeeping protein (PARK7-protein deglycase DJ-1).

RESULTS

Levels of IGFBP7 protein are increased in varicocele. Levels of DNASE1 are progressively decreased in varicocele (lower in varicocele and normal semen analysis, lowest in varicocele and altered semen analysis) when compared to adolescents without varicocele. DNASE1 levels are positively correlated with sperm concentration and morphology (correlation values of 0.400 and 0.404, respectively; p values of 0.001 and 0.001, respectively).

CONCLUSION

In conclusion, in adolescents, seminal plasma levels of IGFBP7, responsible for proliferative activity, are increased in varicocele grades II and III, and DNASE1, responsible for apoptosis regulation, are lower in varicocele, lowest in varicocele and low semen quality. These proteins demonstrate molecular alterations brought upon by varicocele. Moreover, DNASE1 is capable of discriminating a varicocele that causes alterations to semen quality from one that does not. We propose that the initial response of varicocele is to increase proliferative activity which, if followed by regulation of apoptosis, may lead to the ejaculation of a population of sperm that are in accordance with WHO cutoff values but, in the presence of dysregulated apoptosis, leads to lower sperm concentration and morphology.

Does the number of veins ligated during varicococele surgery influence post-operative semen and hormone results?

Varicocele is a well-established cause of male subfertility, which is directly proportional to its clinical grade. Although newer ultrasonic grading systems have taken into account the existence of pampiniform venous plexi, little is known about the clinical significance of the number of veins ligated during surgery. Very few undersized studies reported an influence which triggered the need to evaluate such association. This is a retrospective study of 378 patients who underwent left microsurgical subinguinal varicocoelectomy. Semen analyses and blood hormone studies performed pre-operatively were compared to those executed 6 months after surgery. Patients were divided into abnormal semen and normal semen groups based on their initial semen results. They were also subdivided according to the number of veins ligated intraoperatively into three groups: <5, 5-10, and >10 veins. Sperm count, total motility, and progressive motility were significantly increased in 62, 60.3, and 53.3% of patients post-operatively (p = 0.001), respectively. No significant differences in hormone levels were detected overall. Of the 378 patients, 332 had an abnormal semen analysis, while the remaining 46 patients had a normal result. Sperm count, total motility, and progressive motility significantly increased after varicocoelectomy in patients with an abnormal initial semen analysis (p = 0.001). In 48.7% of patients, 5-10 veins were ligated during surgery, whereas 28.3% had >10 and 23% had <5 ligated veins. No statistically significant differences were noted in the initial or the follow-up results among the number of vein subgroups. Varicocele ligation improves patients' fertility potential. This improvement, however, is not influenced by the number of veins ligated intraoperatively. Clinical grading maintains its superiority in the evaluation of varicocele patients.

Barriers to use of semen analysis in the adolescent with a varicocele: Survey of patient, parental, and practitioner attitudes

BACKGROUND

The American Society for Reproductive Medicine Practice Committee recommends obtaining a semen analysis (SA) in pediatric patients presenting with a varicocele in the absence of significant testicular atrophy. Among infertile adults with a varicocele, surgery is indicated in the presence of abnormal semen analysis regardless of testicular atrophy. Despite these two statements, semen analysis is not widely utilized by pediatric urologists in the USA managing a patient with a varicocele.

OBJECTIVE

We explored the attitudes of patients, parents, and practitioners toward SA to identify potential barriers to the use of SA in the evaluation of the adolescent varicocele.

STUDY DESIGN

We conducted a survey of Society for Pediatric Urology members regarding their management of adolescent varicoceles, with focus on the utilization of SA. The survey consisted of 14 multiple choice questions and two open-ended questions regarding use of SA in practice, barriers to its use, indications for varicocelectomy, and demographics. We also surveyed patients presenting for initial evaluation of a varicocele, as well as their parents, regarding their knowledge about SA and their attitude towards obtaining it. Statistical analysis was performed (p < 0.05 significant).

RESULTS

The practitioner survey response rate was 53% (168). Only 13.1% routinely incorporated SA in their practice, with 48% of all responders having some degree of discomfort asking for a SA. Of practitioners who cited discomfort, 90% never order a SA for patients with varicoceles. From the 46% of physicians who ordered a SA, we noted significant practice variability (see Figure). The patient/parent survey demonstrated that this population was uncomfortable with the notion of obtaining a SA, with most patients/parents citing lack of knowledge about SA as the main barrier. Patient and parent knowledge was found to correlate.

DISCUSSION

This study uniquely addresses an issue that has not been discussed in the adolescent varicocele literature to date. It can increase awareness of the option of incorporating SA data in management of the adolescent who presents with a varicocele.

CONCLUSION

Recognizing and then breaking through the barriers to obtaining a SA, would improve patient care, providing a direct assessment of the impact of a varicocele on fertility potential and thus best determining which patients require surveillance versus surgical intervention. This study suggested that the barriers to SA are surmountable.

My indications for treatment of the adolescent varicocele (and why?)

What to do with the adolescent varicocele? With merging the information obtained from an extensive review of the literature with our own clinical research, I believe that we already have knowledge enough to say that the adolescent with a varicocele often is in the midst of a progressive disease process. Strong evidence already exists that well more than the majority of Tanner 5 boys with a varicocele and 20% asymmetry will already have abnormally low total motile sperm counts (TMCs) and likely abnormally low sperm concentration as well. There are now many studies in addition to common sense to support the value of % asymmetry as a marker of future abnormal sperm parameters. While we know that some boys at lower Tanner stages who present with asymmetry will have catch-up growth during adolescence, we also know that almost all boys with 15% asymmetry or greater in conjunction with a Doppler detected peak retrograde flow (PRF) of 38 cm/s or greater will end up with greater than 20% asymmetry on follow-up. There also are some boys of concern with less asymmetry but instead have small testes bilaterally, perhaps as a result of the left varicocele slowing the growth of the right testicle and/or an associated undetected or overlooked palpable right varicocele that is also negatively affecting the right testicle. Fortunately, we now have another marker available, i.e., total testicular volume (TTV), to assist in decision making for the adolescent falling into this scenario. Once markers are in place in an early Tanner stage boy with a varicocele that indicate that abnormal semen parameters will likely be present when a Tanner 5 stage of development is reached, there is no reason to wait until the child is older so that a semen analysis can be comfortably requested for the documentation. One argument in favor of waiting is that abnormal semen parameters in a Tanner 5 male usually are reversible. However, how do we know that once abnormal parameters are reversed they then will stay normal in a testicle that already has incurred damage. In other words, I feel it is best to operate once the indicators are in place. We do not want to be suddenly surprised when that individual when older has difficulty fathering a child at a time in life when surgery might be too late to resolve what has taken years to develop. Within this manuscript I will try to document my reasons for the aforementioned rationale.

Adolescent Varicoceles and Infertility

Varicoceles are associated with testicular atrophy and abnormal spermatogenesis. Varicocele-related testicular damage is thought to be progressive in nature. Adult varicoceles are common in men with infertility, and varicocele repair in this population has demonstrated improved semen parameters and paternity outcomes. However, without solid objective endpoints (reproducible semen analyses, paternity), the indications for adolescent varicocele repair remain controversial. Given the controversy surrounding adolescent varicocele management, it is not surprising that surveys of pediatric urologists have revealed a lack of consensus on diagnostic approaches, treatment decisions, and operative approaches.

[Impact of varicocele on testicular volume and sperm parameters]

Introduction

La varicocèle est une pathologie masculine fréquente dont l'incidence est encore plus importante dans dans la population des hommes infertiles. Si ses mécanismes sont à ce jour incomplètement expliqués il semble acquis que la varicocèle peut être associée a une dysfonction testiculaire avec diminution du volume testiculaire et de la concentration en spermatozoïde de l’éjaculat.

Méthodes

Dans un premier temps nous exposons les résultats d'une étude rétrospective sur 5 ans (de Mars 2009 à Mars 2014), réalisée au service d'urologie A de l'hôpital Ibn Sina de Rabat et ayant comme objectif d’évaluer l'impact de la varicocèle palpable sur le volume testiculaire et les paramètres spermatiques. Tous les patients inclus dans notre étude avaient une varicocèle palpable. Dans un deuxième temps, et à travers une revue de la littérature nous discutons l'impact du traitement de la varicocèle sur la fertilité.

Résultats

39 patients ont été inclus dans notre étude. L’âge moyen était de 29,71 ans et la varicocèle siégeait dans 89,74% des cas du coté gauche. Une atrophie testiculaire homolatérale à la varicocèle était retrouvée dans 7% des cas alors que des anomalies du spermogramme se voyaient dans 69,23% des cas.

Conclusion

L'impact de la varicocèle sur l'altération des paramètres spermatiques a été clairement établi bien que sa physio pathogénie ne soit pas bien élucidée. Le traitement chirurgical de la varicocèle semble indiqué chez les hommes infertiles présentant une varicocèle clinique et une altération significative du sperme.

Active surveillance of the adolescent with varicocele: predicting semen outcomes from ultrasound

PURPOSE

We hypothesized that active surveillance of the adolescent varicocele is not associated with a high prevalence of suboptimal semen analysis and that patients with abnormal semen analysis have smaller testicular volumes and larger volume differentials.

MATERIALS AND METHODS

We conducted an institutional review board approved retrospective cohort study of adolescents with a clinically detected varicocele. Patients were initially observed by serial scrotal ultrasound evaluating testicular size and differential. Semen analysis was routinely collected in Tanner V cases, around age 18 years. Prevalence of normal semen analysis parameters was calculated, and logistic regression was used to model the ability of age at presentation and testicular volume parameters to predict a normal semen analysis.

RESULTS

A cohort of 73 patients underwent surveillance with a mean ± SD age at presentation of 15.5 ± 2.3 years. Median followup was 2.7 years, during which time subjects underwent a median of 3 scrotal ultrasounds. A low total motile count was found in 48 patients (66%). Neither age at presentation nor testicular volume differential could predict normal semen volume, density, sperm motility or total motile count. Total testicular volume from the final ultrasound predicted total motile count (p = 0.008). However, the collective observations of volume during the entire period of surveillance could not predict total motile count (p = 0.847).

CONCLUSIONS

There is a high prevalence of suboptimal semen analysis in adolescents with a varicocele who are followed with active surveillance. Total testicular volume can predict total motile count at the end of adolescence but not throughout.

[Varicocele and infertility: where do we stand in 2013?]

While the incidence of clinical varicocele is common in infertile men (about 40%), the reasons why varicocele may affect sperm parameters is still unclear. In addition, the improvement of fertility after treatment of varicocele is also a subject of debate. The purpose of this review is to get new insight into the physiopathology of varicocele, its impact on sperm parameters and the effectiveness of varicocele treatment on fertility. Treatment is likely to be effective in infertile men with clinical varicocele and impaired spermatogenesis. Even if it does not systematically lead to an improvement in sperm parameters, it may prevent further sperm degradation. In case of non-obstructive azoospermia, few studies reported a slight improvement in the process of spermatogenesis. The critical role of an adequate methodology in order to establish clinical guidelines needs to be stressed. Indeed, the huge intra-individual variability in sperm production makes the usual analysis of sperm parameters inadequate to measure treatment effectiveness. Regarding the assessment of conception, it requires not only well designed and properly sized studies but also a multivariate analysis for weighing predictive factors of success. Thus, an active scientific research is needed to better identify pathogenic agents and appropriately assess the impact of varicocele treatment.

Adolescent varicocoele management controversies

Varicocoele is defined as excessive dilatation of the pampiniform venous plexus of the spermatic cord. Varicocoele frequently appears during early puberty and is recognized to be the most common surgically correctable cause of male infertility. However, the actual incidence in adolescents, pathophysiology and the association with male factor infertility all remain somewhat controversial. The most accurate diagnostic technique for identifying young men who will benefit from surgical treatment has yet to be established. Observations of testicular asymmetry and deteriorating semen quality helped establish current guidelines and recommendations for surgical treatment. Further studies, comparing observation with surgical intervention, are needed to refine the current indications for varicocoele repair in the adolescent male.

Current issues in varicocele management: a review

The most common cause of male infertility is varicocele, and varicocele is the most common correctable cause of male factor infertility. In this article we reviewed the concept of varicocele in terms of its diagnosis, method of treatment, indications for treatment, treatment outcomes, and prognostic factors. Physical examination is an essential diagnostic tool in the evaluation of a patient with a varicocele. However, as it depends on subjective findings, standardization of the physical examination method is needed. Various methods for treatment of varicocele exist, including open surgical, laparoscopic, microscopic surgical, and radiologic treatment such as embolization. Among these treatment approaches, microscopic inguinal or subinguinal varicocelectomy has superior outcomes, with a low complication rate. The influence of the treatment of varicocele on fertility is still a controversial issue and a difficult question to address, because there are limitations to performing a randomized control study, and previous studies had a heterogeneity of subjects and high dropout rate. However, there is robust evidence that varicocelectomy improves semen parameters as a surrogate marker of the potential for fertility. To date, general indications for treatment of varicocele are limited in patients with proven infertility, clinical palpable varicocele, and abnormal semen characteristics. Recently, it was shown that some symptoms other than infertility could be an indication for varicocelectomy because these symptoms are frequently related to deterioration of semen parameters. Varicocele in the adolescent presents a more difficult decision regarding whether to treat. A testicular size discrepancy of more than 20% is helpful for treatment decisions. Various prognostic factors were noted in several studies without, however, a consistent consensus.

Insight into oxidative stress in varicocele-associated male infertility: part 2

Varicocele, the leading cause of male infertility, can impair spermatogenesis through several pathophysiological mechanisms. Of these, current evidence suggests that oxidative stress is the central element contributing to infertility in men with varicocele, to which the testis responds by way of heat stress, ischaemia or production of vasodilators, such as nitric oxide. Surgical varicocele repair (varicocelectomy) is beneficial not only for alleviating oxidative stress-associated infertility, but also for preventing and protecting against the progressive character of varicocele and its consequent upregulations of systemic oxidative stress. However, antioxidant therapy in infertile men with surgically treated and those with untreated varicocele is poorly studied, and well-designed trials are needed.

Microsurgical varicocelectomy: a review

Varicocelectomy is the most commonly performed surgical procedure for the treatment of male infertility. Although several different techniques for varicocele repair have been described in the literature, microsurgical varicocelectomy performed through a subinguinal or inguinal incision is recognized as the gold-standard approach for varicocelectomy, due to high success rates with minimal complications. Standard indications for varicocelectomy include palpable varicocele(s), with one or more abnormal semen parameters, and, for the couple trying to conceive, in the setting of normal or correctable female infertility. However, varicocele repair is often recommended and undertaken for reasons other than infertility, including low serum testosterone, testicular pain, testicular hypotrophy and poor sperm DNA quality. This article reviews the technical aspects of microsurgical varicocelectomy, and its indications in adults and adolescents.

Varicocele in younger as risk factor for inguinal hernia and for chronic venous disease in older: preliminary results of a prospective cohort study

BACKGROUND

Varicocele, inguinal hernia, and chronic venous insufficiency are often associated. Varicocele has its maximum prevalence in younger age, whereas hernia and chronic venous disease appear later. The aim of this study was to analyze the relationship between these conditions.

METHODS

A prospective cohort study was conducted, consisting of two groups of male patients. Group A comprised patients with varicocele, whereas group B comprised those with problems other than varicocele. Both groups were followed over time and were assessed for the onset of signs and symptoms related to inguinal hernia and chronic venous disease.

RESULTS

Preliminary results showed a positive correlation between the presence of varicocele in younger and the possible risk of hernia and/or chronic venous disease in later age.

CONCLUSIONS

Preliminary results suggest that varicocele in younger age appears to be an early marker of progression for a connective tissue-related disease in later age.

Current management principles for adolescent varicocele

The authors review the current approach to management of the adolescent varicocele which has evolved over the past two decades. Principles of observational, surgical and adjunctive management are discussed relative to significant clinical findings. A selective approach to surgical intervention is advocated with the goal of preserving fertility potential.

Surgical treatment of male infertility in the era of intracytoplasmic sperm injection - new insights

Assisted reproductive technology is an evolving area, and several adjuvant procedures have been created to increase a couple's chance of conceiving. For male infertility, the current challenges are to properly accommodate old and new techniques that are both cost-effective and evidence-based. In this context, urologists are expected to diagnose, counsel, provide medical or surgical treatment whenever possible and/or correctly refer male patients for assisted conception. Urologists are sometimes part of a multiprofessional team in an assisted reproduction unit and are responsible for the above-cited tasks as well as the surgical retrieval of sperm from either the epididymides or testicles. We present a comprehensive review of the surgical treatment options for infertile males, including the perioperative planning and prognostic aspects, with an emphasis on the role of microsurgery in the optimization of treatment results. This review also discusses current techniques for sperm retrieval that are used in association with assisted reproductive technology and includes sperm retrieval success rates according to the technique and the type of azoospermia. New insights are provided with regard to each surgical treatment option in view of the availability of assisted conception to overcome male infertility.

Nationwide survey to evaluate the prevalence of varicoceles in South Korean middle school boys: a population based study

OBJECTIVE

We carried out a nationwide epidemiological study to evaluate the prevalence and effect of varicoceles on testicular volume in South Korean adolescents. We also investigated the correlation between varicoceles and body mass index (BMI).

METHODS

In this prospective study, physical examinations were carried out to assess the presence and severity of varicoceles in middle school boys from six regions of South Korea. Testicular volume, height and weight of all boys were measured. The prevalence of varicoceles was assessed. The associations between age, testicular volume, BMI, and the presence and severity of varicoceles were examined.

RESULTS

A total of 1938 boys with a mean age of 14.1 years (range 13-16 years) were screened. A varicocele was found on the left side in 295 (15.2%) boys and on the right side in 8 (0.4%) boys. Bilateral varicoceles were found in 17 (0.9%) individuals. Of the subjects with a left varicocele, 151 (51.2%), 80 (27.1%) and 64 (25.1%) boys had a grade 1, 2 or 3 varicocele, respectively. The prevalence of varicoceles did not increase with age. The proportion of boys with testicular size discrepancies increased with the severity of the varicocele. After adjusting for age, BMI had a negative correlation with the presence of varicoceles.

CONCLUSIONS

The prevalence of varicoceles in South Korean middle school boys is 16.5%. The presence of varicoceles seems to have a negative effect on testicular growth. BMI has a significant inverse relationship with the occurrence of varicoceles.

Treatment strategy for the adolescent varicocele

A varicocele is a dilatation of the testicular vein and the pampiniform venous plexus within the spermatic cord. Although rare in pediatric populations, the prevalence of varicoceles markedly increases with pubertal development. Varicoceles are progressive lesions that may hinder testicular growth and function over time and are the most common and correctable cause of male infertility. Approximately 40% of men with primary infertility have a varicocele, and more than half of them experience improvements in semen parameters after varicocelectomy. The decision to treat adolescents with varicocele is a controversial one. The task for pediatricians and urologists is to identify those adolescents who are at greatest risk for infertility in adulthood, in an effort to offer early surgical intervention to those most likely to benefit.

Expression of the Fas-ligand gene in ejaculated sperm from adolescents with and without varicocele

PURPOSE

To assess FasL mRNA levels in ejaculated sperm from adolescent patients with and without varicocele.

METHODS

Semen was obtained by masturbation following 2-4 days of ejaculatory abstinence, from 14 adolescents with varicocele grades II and III (study group), and 20 adolescents without varicocele (control group). Seminal analysis was done according to World Health Organization guidelines and morphology using Kruger's strict criteria. The Fas-ligand (FasL) gene expression was performed using reverse transcription and real-time quantitative polymerase chain reaction (RQ-PCR) analysis, according to the expression level of the housekeeping cyclophilin A gene. A Student's t-test was applied to compare the groups, and Spearman's rank test in order to verify possible correlations (p < 0.05).

RESULTS

Quantitative RQ-PCR demonstrated that the expression of FasL mRNA in sperm from the varicocele group was higher than in the control group. Also, sperm concentration was higher in the controls, when compared to the varicocele group. When submitted to correlation analysis, adolescents with varicocele presented a correlation between sperm concentration and FasL gene expression levels (r = -0.470), not observed in controls.

CONCLUSION

Our results allow us to conclude that, in adolescents with varicocele presenting lower sperm concentration, FasL mRNA levels are higher than in adolescents without varicocele.

Gonadal vein embolization: treatment of varicocele and pelvic congestion syndrome

Therapeutic embolization of the gonadal veins is performed on male and female patients for different clinical situations using similar techniques. The testicular varicocele is a common clinical problem associated with pain and reduced fertility rates. In women, chronic pelvic pain can be attributed to pelvic congestion syndrome, which is said to result from retrograde flow in incompetent ovarian veins. Both of these clinical problems respond well to gonadal vein embolization. In this article, we review the clinical evaluation, diagnostic workup, and technical aspects of percutaneous intervention of gonadal vein embolization. The supporting literature is also reviewed.