Le traitement chirurgical de la varicocèle améliore la fertilité et aide à la procréation médicalement assistée

[Results of subinguinal microsurgical varicocelectomy]

INTRODUCTION

The subinguinal microsurgical varicocelectomy is considered as the gold standard surgical technique for the treatment of varicocele. The objective of this study is to evaluate the results of this technique on the resolution of pain and the parameters of sperm analysis.

METHODS

Single-center, retrospective study that includes 22 patients who have been operated over a period of six months for a clinically palpable varicocele via the microsurgical subinguinal technique. Nine patients were operated for pain and 13 patients for infertility with an abnormality of their sperm analysis.

RESULTS

All the patients operated for pain had a complete resolution of pain at the postoperative follow-up (3 months). Concerning the patients operated for infertility, 76.92% of the patients had a normal sperm analysis, 7.69% of the patients presented a partial improvement, and 15.39% of the patients without any improvement. Analysis of sperm's parameters at 3 months showed a significant improvement in the morphology (4.3% vs 6.69% of typical forms according to Kruger ; P<0.05) and mobility (progressive mobility 15.6% vs 23% postoperatively; P<0.01). A non-significant improvement (low sample) in the concentration was noted (21.58 million/mL preoperative vs 34.9 million/mL postoperative, P=0.08). Pregnancies are noted in 38.5% of patients. A postoperative complication was noted with surgical site infection resolved with antibiotics.

CONCLUSION

This single-center study confirms that the treatment of varicocele by subinguinal microsurgical route is an effective therapeutic strategy on symptomatic varicocele and in infertile men. This technique is associated with few complications.

LEVEL OF EVIDENCE: 4

Developing a novel prediction model for the impact of varicocelectomy on postoperative fertility

The objective of this study was to evaluate inflammatory markers as predictors of fertility after varicocelectomy and to develop a prediction model. This prospective cohort was conducted on patients with varicoceles who were presented to the clinic of Imam Reza hospital of Tehran during 2019-2020. Semen analysis, complete blood count (CBC), and scrotal ultrasonography was requested. Patients with abnormalities of semen analysis were chosen as candidates for varicocelectomy. 6 months after the operation, semen analysis was repeated. Hematologic and semen analysis parameters were recorded at baseline and follow-up visits. Treatment success was defined as 50% increase in total motile sperm count (TMSC) in cases with preoperative TMSC> 5 million/cc or 100% increase in TMSC in cases with preoperative TMSC< 5 million/cc. Patients were then categorized into two groups based on treatment success and statistical analysis was performed on these two groups. 124 infertile patients with varicocele were evaluated in our study. 52 patients (41.93%) showed improvements in semen analysis after varicocelectomy. After univariate and multivariate analysis three parameters were used in our predictive model as body mass index (BMI)>23.70 kg/m2 (4 scores), neutrophil-lymphocyte ratio (NLR) >1.80 (3 scores), and TMSC<14.69 million (2 scores). A cut-off value of 5 was associated with an 87.5% sensitivity and an 84.6% specificity for the prediction of failure of varicocelectomy. Varicocelectomy can improve semen analysis parameters in almost all infertile men with varicocele. Using BMI, NLR, and baseline TMSC as the suggested scoring system can predict the success of varicocelectomy for improving fertility and determine the appropriate infertile candidates for surgery.

[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.

Varicocèle et infertilité masculine

Introduction

La responsabilité de l’homme dans l’infertilité du couple est établie par plusieurs travaux. Le but de ce travail est de rapporter les aspects cliniques, spermiologiques de la varicocèle et d’évaluer les résultats de la varicocélectomie rétropéritonéale à ciel ouvert.

Patients et méthodes

Il s’agit d’une étude rétrospective évaluant les résultats de la varicocélectomie rétropéritonéale à ciel ouvert, dans le service d’urologie-andrologie du centre hospitalier et universitaire Aristide-Le-Dantec de Dakar, Sénégal. Nous nous sommes intéressés aux patients suivis pour infertilité du couple, porteurs de varicocèle et chez la (les) partenaire(s) de qui aucune autre cause d’infertilité n’a été décelée. Pour l’évaluation des résultats, nous avons comparé les moyennes des paramètres spermatiques pré-et postopératoires en utilisant le test Z (test de comparaison de deux moyennes sur deux séries appariées). Une différence était considérée comme significative si p inférieur ou égal à 0,05.

Résultats

Cinq cent quatorze dossiers ont été retenus au cours de l’exploitation sur une période de six ans (janvier 2005–décembre 2010). L’âge moyen de nos patients était de 36,5 ± 7,3 ans. L’infertilité était primaire dans 62,4 %. L’exploitation des spermogrammes préopératoires a permis de noter que l’oligozoospermie sévère (33,7 %) était associée à des degrés divers à une asthénozoospermie et à une thératozoospermie. Ces patients étaient suivis avec un recul moyen de 22 mois (6–48 mois). L’amélioration des paramètres spermatiques était significative, concernant la concentration et la mobilité des spermatozoïdes. Le taux de grossesses naturelles obtenu dans la série était de 20,8 %. Aucun cas de grossesse naturelle n’a été noté dans le groupe des patients présentant une azoospermie, mais une induction de la spermatogenèse a été notée dans 20,5 % des cas. Près de deux grossesses sur trois (64 %) ont été notées durant les 12 premiers mois postopératoires.

Conclusion

Le traitement chirurgical de la varicocèle permet d’améliorer les paramètres spermatiques, ce qui non seulement permet l’obtention de grossesses naturelles mais également de simplifier les techniques d’Assistance Médicale à la Procréation (AMP) prévues grâce aux nouveaux paramètres.

Varicocele repair: does it still have a role in infertility treatment?

PURPOSE OF REVIEW

To review the role of varicocele repair in the treatment of male infertility.

RECENT FINDINGS

Since the advent of technologies bypassing boundaries of natural selection, this question may seem outdated. Over the past 20 years, fertility has decreased, and testicular damage (cryptorchidism, tumors) has increased. Thus the exploration of the infertile male is still unavoidable. However, what should be done and assigned to the discovery of a varicocele?The issue raised is whether varicocele found during the review of the infertile couple should be treated or 'ignored'.This study will update significant findings with regards to the pathophysiology of varicocele-induced infertility, such as oxidative stress and role of varicocele in bilaterality of testicular damage. Benefits of varicocele repair in semen analysis and simplifications of assisted reproductive techniques are reported. But reviews of randomized clinical trials have raised doubts about the benefit of varicocele treatment in infertile men.

SUMMARY

We conclude that varicocele repair may be effective in men with subnormal semen analysis, a clinical varicocele and otherwise unexplained infertility. Deleterious cofactors, like obesity or smoking, could also be reduced for the benefit of general health and fertility.

Preserved testicular artery at varicocele repair

Whether or not varicocele causes infertility is a contentiously debated issue. This study aimed to compare semen parameters and pregnancy rate in infertile males who underwent varicocelectomy with preserved or accidentally ligated testicular artery. Ninety-five infertile oligoasthenozoospermic patients with left-sided varicocele were subjected to subinguinal varicocelectomy with trial of preserving testicular artery. According to absence or presence of testicular artery in the histological excised pedicle the cases were divided into two groups; group 1 (n = 60) with preserved testicular artery and group 2 (n = 35) where the artery was accidentally ligated being not defined or injured. Semen analysis was carried out after 4, 8 and 12 months and post-operative pregnancy rate was assessed after 1 year. Serum follicle-stimulating hormone (FSH), luteinising hormone (LH) and total testosterone (T) were estimated pre- and post-operatively. Semen parameters (total sperm count, sperm concentration and sperm motility) showed significant increase post-operatively compared with pre-operative parameters but were comparable in both groups with no significant difference. Serum FSH, LH, T hormones and pregnancy rate (23.3% versus 22.9%) 1 year post-operatively showed no significant difference. It is concluded that accidental ligation of testicular artery has no deleterious effect on semen parameters during primary varicocele repair if the testicular arterial supply was not compromised.