Quantitative evaluation of testicular biopsies in varicocele

Shear-wave elastography for the assessment of testicular involvement of hematologic malignancies in children and young adults: a feasibility study

Purpose

This study aimed to assess the feasibility of shear-wave elastography (SWE) for assessing the testicular involvement of hematologic malignancies in children and young adults.

Methods

Eight patients (mean age, 11.0 years; range, 0.8 to 20 years) with biopsy-confirmed testicular involvement of hematologic malignancy between January 2018 and December 2020 were retrospectively evaluated. Multiparametric ultrasound examinations, including grayscale, color Doppler ultrasonography (CDUS), and SWE, were performed. Stiffness was measured in the involved testicular area and contralateral normal parenchyma. If there was bilateral testicular involvement, the stiffness of the involved area and the adjacent normal echoic parenchyma was measured on one testis. The Mann-Whitney U test was used to compare stiffness values.

Results

On grayscale, the testicular lesions were noted as a solitary mass in one patient, multiple lesions in four patients, and diffuse involvement in three patients. On CDUS and SWE, all patients demonstrated increased vascularity, and the stiffness of the involved area was higher than the values of normal parenchyma (the involved area vs. normal parenchyma, 11.6 kPa [3.9-20.2 kPa] vs. 2.9 kPa [1.1-3.7 kPa], P=0.003). The ratio of stiffness between the involved area and normal parenchyma was 3.4, ranging from 1.9 to 5.1. One patient showed decreased stiffness on follow-up SWE after treatment (affected testis vs. normal testis: initial, 13.8 vs. 3.2 kPa; 1 year later, 2.2 vs. 2.4 kPa).

Conclusion

Increased testicular stiffness on SWE in children and young adults with hematologic malignancies suggests the possibility of testicular involvement.

Outcome of varicocele repair in men with nonobstructive azoospermia: systematic review and meta-analysis

The objective of this systemic review was to evaluate the benefit of repairing clinical varicocele in infertile men with nonobstructive azoospermia (NOA). The surgically obtained sperm retrieval rate (SRR) and pregnancy rates following assisted reproductive technology (ART) with the use of retrieved testicular sperm were the primary outcomes. The secondary outcomes included the presence of viable sperm in postoperative ejaculate to avoid the testicular sperm retrieval and pregnancy rates (both assisted and unassisted) using postoperative ejaculated sperm. An electronic search to collect the data was performed using the MEDLINE and EMBASE databases until April 2015. Eighteen studies were included in this systematic review and accounted for 468 patients who were diagnosed with NOA and varicocele. These patients were subjected to either surgical varicocele repair or percutaneous embolization. Three controlled studies evaluating sperm retrieval outcomes indicated that in patients who underwent varicocelectomy, SRR increased compared to those without varicocele repair (OR: 2.65; 95% CI: 1.69–4.14; P < 0.001). Although pregnancy rates with the use of testicular sperm favored the varicocelectomy group, results were not statistically significant (clinical pregnancy rate OR: 2.07; 95% CI: 0.92–4.65; P = 0.08; live birth rate OR: 2.19; 95% CI: 0.99–4.83; P = 0.05). The remaining fifteen studies reported postoperative semen analysis results. In 43.9% of the patients (range: 20.8%–55.0%), sperm were found in postoperative ejaculates. Pregnancy rates for unassisted and assisted (after IVF/ICSI) were 13.6% and 18.9% in the group of men with sperm in postoperative ejaculates, respectively. Our findings indicate that varicocelectomy in patients with NOA and clinical varicocele is associated with improved SRR. In addition, approximately 44% of the treated men will have enough sperm in the ejaculate to avoid sperm retrieval. Limited data on pregnancy outcomes with both postoperative ejaculated sperm and harvested testicular sperm preclude any firm conclusion with regard to the possible increased fertility potential in treated individuals. In conclusion, the results of our study indicate that infertile men with NOA and clinical varicocele benefit from varicocelectomy. Given the low/moderate quality of evidence available, it is advisable that doctors discuss with their patients with NOA the risks and benefits of varicocele repair.

Transcriptome research on spermatogenic molecular drive in mammals

It is known that spermatogenic disorders are associated with genetic deficiency, although the primary mechanism is still unclear. It is difficult to demonstrate the molecular events occurring in testis, which contains germ cells at different developmental stages. However, transcriptomic methods can help us reveal the molecular drive of male gamete generation. Many transcriptomic studies have been performed on rodents by utilizing the timing of the first wave of spermatogenesis, which is not a suitable strategy for research in fertile men. With the development of separation methods for male germ cells, transcriptome research on the molecular drive of spermatogenesis in fertile men has seen great progress, and the results could be ultimately applied to improve the diagnosis and treatment for male infertility.

Spermatogenesis in humans and its affecting factors

Spermatogenesis is an extraordinary complex process. The differentiation of spermatogonia into spermatozoa requires the participation of several cell types, hormones, paracrine factors, genes and epigenetic regulators. Recent researches in animals and humans have furthered our understanding of the male gamete differentiation, and led to clinical tools for the better management of male infertility. There is still much to be learned about this intricate process. In this review, the critical steps of human spermatogenesis are discussed together with its main affecting factors.

Recovery of spermatogenesis after microsurgical subinguinal varicocele repair in azoospermic men based on testicular histology

OBJECTIVE

Analyze whether testicular histologic patterns from a group of azoospermic men with varicocele is predictive of treatment outcome after subinguinal microsurgical varicocele repair.

MATERIALS AND METHODS

Seventeen azoospermic men underwent bilateral open single testis biopsy and microsurgical subinguinal repair of clinical varicoceles.

RESULTS

Histopathology of testicular biopsies revealed hypospermatogenesis (HYPO) in 6 men, maturation arrest (MA) in 5, and Sertoli cell-only (SCO) in 6. Overall, presence of spermatozoa in the ejaculates was achieved in 47% (8/17) of men after varicocele repair, but only 35% (6/17) of them had motile sperm in their ejaculates. Only men with testicular histology revealing HYPO (5/6) or maturation arrest (3/5) had improvement after surgery. Median (25%-75% percentile) postoperative motile sperm count for both groups were 0.9 x 10(6)/mL (0.1-1.8 x 10(6)/mL) and 0.7 x 10(6)/mL (0.1-1.1), respectively (p = 0.87). The mean time for appearance of spermatozoa in the ejaculates was 5 months (3 to 9 months). One (HYPO) of 8 (12.5%) men who improved after surgery contributed to an unassisted pregnancy. Postoperative testicular biopsies obtained from patients who had no improvement after surgery revealed that testicular histology diagnosis remained unchanged. Successful testicular sperm retrieval for intracytoplasmic sperm injection (ICSI) was achieved in 4 of 9 (44.4%) individuals who did not improve after surgery, including 1 man with testicular histology exhibiting SCO.

CONCLUSIONS

Microsurgical varicocele repair in nonobstructive azoospermic men with clinical varicoceles can result in sperm appearance in the ejaculate when hypospermatogenesis or maturation arrest is found on testicular histology diagnosis.

The safety of ultrasonically guided testis aspiration biopsies and efficacy of use to predict varicocelectomy outcome

BACKGROUND

We hypothesized that infertile men with varicoceles have molecular/genetic defects that interact with varicoceles to induce infertility. Studies directly on testis tissue appeared to be a way to link histology, markers for molecular/genetic defects and spermatogenesis, but testis biopsies may induce morbidity. In this report, we present safety and efficacy data on ultrasonically guided, single stick, percutaneous aspiration.

METHODS

Biopsies were performed on 115 infertile men with varicoceles and five men with obstructive azoospermia. Morbidity was examined by pre- and post-biopsy ultrasound, efficacy by ability of two markers to predict >50% increase in sperm density post-operatively. All patients had three pre- and three post-operative semen analyses.

RESULTS

78.3% of patients had no ultrasonic testicular defects immediately post-biopsy. By 2 months, 100% had no defects. Biopsy markers [testicular cadmium (<0.453 ng/mg tissue) and an intact calcium channel mRNA sequence] predicted >50% increase in sperm density with 82.9 and 90.5% accuracy, respectively.

CONCLUSIONS

Ultrasonically controlled, percutaneous aspiration testis biopsies are safe. Specimens so acquired can assist study of molecular/genetic markers associated with spermatogenesis in infertile men with varicoceles. Tissue cadmium level, calcium channel sequence and other markers may predict outcome of varicocele surgery.

Elevation of serum testosterone and free testosterone after embolization of the internal spermatic vein for the treatment of varicocele in infertile men

BACKGROUND

To evaluate the effect of internal spermatic vein (ISV) embolization on levels of serum testosterone and free testosterone and on spermatogenesis.

METHODS

The files of 83 infertile men treated for varicocele were reviewed for changes in serum testosterone, free testosterone and spermatogenesis after ISV embolization.

RESULTS

Mean serum testosterone concentration rose after embolization by 43%, from 12.07 +/- 6.07 nmol/l to 17.22 +/- 8.43 nmol/l (P<0.001). Mean serum free testosterone concentration rose by 72%, from 5.93 +/- 2.44 nmol/l to 10.21 +/- 7.69 nmol/l (P<0.001). Mean sperm concentration increased from 7.49 +/- 1.73 x 10(6)/ml to 18.14 +/- 2.36 x 10(6)/ml (P<0.001); mean sperm motility increased from 21.74 +/- 2.47 to 34.47 +/- 2.27% (P<0.001); and mean sperm morphology increased from 6.63 +/- 1.07 to 13.08 +/- 1.44% (P<0.001).

CONCLUSIONS

ISV embolization apparently induces an increase in both serum testosterone and free testosterone concentrations and in sperm parameters in infertile patient with varicocele, regardless of the size of the varicocele.

The adolescent varicocele: treatment and outcome

At present, it is reasonable to counsel all patients, as well as family members of patients, who have a palpable varicocele about the long-term risks for impaired fertility. Currently, no one can predict with absolute certainty if any adolescent with a varicocele will be at risk for future infertility. Based on existing data, however, it is not reasonable simply to ignore the potential for such a problem until infertility becomes an issue because by that time the chance for reversibility may be lost. It is important to present a balanced discussion because the majority of men with a varicocele will be fertile, and no one is suggesting that all men with a varicocele undergo surgical treatment. Current recommendations for repair are based on the findings of impaired testicular growth and/or spermatogenesis. With early evaluation and selective treatment, however, we should be able to reduce the potential for future fertility problems significantly in adolescents with a varicocele.

Adolescent varicocele

The evaluation and management of adolescents with varicoceles continue to evolve. Current recommendations for repair are based on the findings of impaired testicular growth or spermatogenesis; however, with early evaluation and selective treatment, clinicians should be able to reduce the potential for future fertility problems significantly in adolescents with varicoceles.

Unilateral or bilateral testicular biopsy in the era of intracytoplasmic sperm injection

PURPOSE

Intracytoplasmic sperm injection has significantly improved the treatment of male infertility. Since only single vital spermatozoa are required for successful fertilization, the value of unilateral or bilateral diagnostic testicular biopsies in patients with azoospermia is controversial. We evaluated differences in bilateral testicular biopsies in azoospermic patients with regard to testicular histology and focal spermatogenesis.

MATERIALS AND METHODS

Histopathological results of 100 testicular biopsies from 50 patients (mean age 33.3 years) were reviewed. In all cases azoospermia was the indication for diagnostic testicular biopsy. Intra-individual differences of bilateral testicular biopsies were retrospectively reviewed by determining the latest stage of spermatogenesis.

RESULTS

After bilateral biopsy a difference in testicular histology was found in 28% and identical histopathology was noted in 70% of patients. An unsuspected burned out seminoma with maturation arrest in the contralateral testis was seen in 2% of cases. Testicular symmetry determined by a Prader orchidometer was noted in 54.8% of patients whereas 45.2% had asymmetrical testis. The frequency of divergent histopathologies in relation to testicular symmetry was 21.7 and 26.3%, respectively. Spermatozoa were found in 42% of right and 44% of left testes (p >0.05), and spermatids as the latest stage of differentiation were detected in 14 and 16%, respectively (p >0.05). Differentiation of testicular histologies according to the side of biopsy revealed spermatozoa and/or spermatids in 56% of right and 58% of left testes (p >0.05). Bilateral biopsies increased the detection of focal spermatogenesis to 68%. If only unilateral diagnostic testicular biopsies had been performed, in 20% of patients focal spermatogenesis in the contralateral testis would have been missed.

CONCLUSIONS

Bilateral testicular biopsies are superior to unilateral biopsies in the evaluation of patients with azoospermia. A 28% intra-individual difference in testicular pathology was seen after bilateral biopsies, and in 20% of patients focal spermatogenesis would have been missed after unilateral biopsy only. Due to the prognostic relevance of testicular biopsies for successful sperm retrieval before assisted reproduction, bilateral diagnostic testicular biopsies are recommended in the evaluation of patients with azoospermia.

Sperm dysfunction in subfertile patients with varicocele and marginal semen analysis

A comparative analysis of potentially functional spermatozoa per ejaculate, progressive motility, hypo-osmotic swelling test, acrosome integrity and sperm viability (24 and 48 h) was carried out in a group of 40 subfertile patients with varicocele and marginal semen analysis and 40 fertile subjects, in order to identify subclinical abnormalities that may explain subfertility. Patients with varicocele had lower numbers of potentially functional spermatozoa per ejaculate, progressive motility, acrosome and membrane integrity and sperm viability. These abnormalities were not related to the grade of varicocele, testicular volume or serum FSH concentration. A positive correlation between the hypo-osmotic swelling test and progressive motility (r = 0.71) and between potentially functional spermatozoa and the hypo-osmotic swelling test (r = 0.69) was found in patients with varicocele. These data suggest that some of the deleterious effects produced by the varicocele might be related to sperm migration and viability in the female genital tract and others to sperm-zona interaction and/or sperm-egg fusion.

Rodent Leydig cell tumorigenesis: a review of the physiology, pathology, mechanisms, and relevance to humans

Leydig cells (LCs) are the cells of the testis that have as their primary function the production of testosterone. LCs are a common target of compounds tested in rodent carcinogenicity bioassays. The number of reviews on Leydig cell tumors (LCTs) has increased in recent years because of its common occurrence in rodent bioassays and the importance in assessing the relevance of this tumor type to humans. To date, there have been no comprehensive reviews to identify all the compounds that have been shown to induce LCTs in rodents or has any review systematically evaluated the epidemiology data to determine whether humans were at increased risk for developing LCTs from exposure to these agents. This review attempts to fill these deficiencies in the literature by comparing the cytology and ontogeny of the LC, as well as the endocrine and paracrine regulation of both normal and tumorigenic LCs. In addition, the pathology of LCTs in rodents and humans is compared, compounds that induce LC hyperplasia or tumors are enumerated, and the human relevance of chemical-induced LCTs is discussed. There are plausible mechanisms for the chemical induction of LCTs, as typified by agonists of estrogen, gonadotropin releasing hormone (GnRH), and dopamine receptors, androgen receptor antagonists, and inhibitors of 5alpha-reductase, testosterone biosynthesis, and aromatase. Most of these ultimately involve elevation in serum luteinizing hormone (LH) and/or LC responsiveness to LH as proximate mediators. It is expected that further work will uncover additional mechanisms by which LCTs may arise, especially the role of growth factors in modulating LC tumorigenesis. Regarding human relevance, the pathways for regulation of the hypothalamo-pituitary-testis (HPT) axis of rats and humans are similar, such that compounds that either decrease testosterone or estradiol levels or their recognition will increase LH levels. Hence, compounds that induce LCTs in rats by disruption of the HPT axis pose a risk to human health, except for possibly two classes of compounds (GnRH and dopamine agonists). Because GnRH and prolactin receptors are either not expressed or are expressed at very low levels in the testes in humans, the induction of LCTs in rats by GnRH and dopamine agonists would appear not to be relevant to humans; however, the potential relevance to humans of the remaining five pathways of LCT induction cannot be ruled out. Therefore, the central issue becomes what is the relative sensitivity between rat and human LCs in their response to increased LH levels; specifically, is the proliferative stimulus initiated by increased levels of LH attenuated, similar, or enhanced in human vs. rat LCs? There are several lines of evidence that suggest that human LCs are quantitatively less sensitive than rats in their proliferative response to LH, and hence in their sensitivity to chemically induced LCTs. This evidence includes the following: (1) the human incidence of LCTs is much lower than in rodents even when corrected for detection bias; (2) several comparative differences exist between rat and human LCs that may contribute, at least in part, to the greater susceptibility of the rat to both spontaneous and xenobiotic-induced LCTs; (3) endocrine disease states in man (such as androgen-insensitivity syndrome and familial male precocious puberty) underscore the marked comparative differences that exist between rats and man in the responsiveness of their LC's to proliferative stimuli; and (4) several human epidemiology studies are available on a number of compounds that induce LCTs in rats (1,3-butadiene, cadmium, ethanol, lactose, lead, nicotine) that demonstrate no association between human exposure to these compounds and induction of LC hyperplasia or adenomas. (ABSTRACT TRUNCATED)

Simultaneous microsurgical vasal reconstruction and varicocele ligation: safety profile and outcomes

OBJECTIVES

Simultaneous varicocele ligation and vasal reconstruction has previously been avoided because of concern regarding testicular devascularization. This study sought to investigate the safety of a simultaneous combined approach in the hands of an experienced microsurgeon.

METHODS

A retrospective review was conducted of the records of 47 men who underwent vasal reconstruction, 10 (21%) of whom had simultaneous ligation of a clinically palpable varicocele. Specific attention was focused on the development of postoperative testicular atrophy and hydrocele and the analysis of postoperative semen parameters.

RESULTS

No patient developed postoperative testicular atrophy or hydrocele. No statistically significant difference existed in postoperative seminal parameters between those patients who had vasal reconstruction alone and those who had a combined procedure.

CONCLUSIONS

In the hands of an experienced microsurgeon, simultaneous vasal reconstruction and varicocele ligation is a management strategy that has an excellent safety profile. This approach is not recommended for the occasional microsurgeon.

Relationship between grade of varicocele and the response to varicocelectomy

BACKGROUND

Although several studies indicate that larger varicoceles are associated with greater impairment of spermatogenesis, others suggest that the response to surgery is independent of varicocele size. In order to elucidate these seeming contradictions, correlations between the preoperative evaluation of varicoceles and improvement in semen quality after varicocelectomy were investigated.

METHODS

Forty men with left unilateral varicocele, followed for at least 6 months after varicocelectomy, were included in this study. The relationships between the grade of varicocele by palpation, Doppler examination, ultrasound, or scintigraphy were correlated with a postoperative improvement in sperm density or sperm motility.

RESULTS

Greater improvement in sperm density was observed in the patients with a large varicocele graded by palpation or measured by ultrasound, and greater improvement in sperm motility was observed in the patients with high uptake of radioactivity in the left side by scrotal scintigraphy.

CONCLUSION

An improvement in semen quality after varicocelectomy is greater in patients with a large varicocele than in the patients with a small one. The significance of surgical repair of a small varicocele should be reconsidered.

Objective assessment of spermatogenesis in men with functional and anatomic obstruction of the genital tract

Experimental rodent models simulating the condition of neurogenic infertility have drawn attention to the role of potential epididymal dysfunction as an underlying cause. This functional obstruction of the genital tract is comparable to the outcome of genital tract obstruction after vasectomy, and may explain the common finding of asthenospermia in both groups following either stimulated semen recovery or vasovasostomy, respectively. Since spermatogenic dysfunction has been reported in spinal cord injury, the relative roles of defective sperm production and sperm transport remain to be determined in men with neurogenic infertility. The objective of this study was to compare the levels of spermatogenesis in groups of vasectomized men and those with spinal cord injury, using objective measurement criteria for spermatogenesis. Groups of 10 spinal cord-injured and six vasectomized men matched for age and duration of disease, underwent incisional testicular biopsy. The specimens were divided equally for parallel quantitation of spermatogenesis by both quantitative cytometry and DNA flow cytometric analysis. Quantitative parameters showed similar values for both groups with reference to mean tubular wall thickness, mean tubular concentration of spermatids and Sertoli cells, as well as the mean spermatid: Sertoli cell ratio per tubule. Additionally, similar percentages of 1N, 2N and 4N cells, were found in both groups. Based on these preliminary findings this study provides a clinical correlation supporting the experimental observation that both anatomical and functional obstruction of the male genital tract exert a similar although minor spermatogenic insult, and that in both the putative cause for neurogenic infertility is more likely to be at the post-testicular level.

Asymptomatic varicocele testis

The incidence of asymptomatic varicocele among 542 unselected military conscripts in Denmark was 9%. Semen from 39 of the 49 men with varicocele was compared with findings in age-matched, varicocele-free controls. The overall quality of the semen was reduced in the varicocele group (p < 0.001), with significantly lower parameters of sperm concentration, total sperm count, qualitative motility and sperm motility after 24 hours. There was also significant difference in morphology, with more amorphous spermatozoa and more with tail defects (p < 0.05) in the varicocele group. The study indicated an association between asymptomatic varicocele and compromised sperm quality. The advisability of surgical treatment was not clarified, but the two groups of men will be further observed with special regard to this question.

Anatomical characteristics of the left testicular venous system in man

Autopsy was performed on 49 male cadavers and the entire course of the left testicular vein (LTV) was studied. The testicular venous pathway was divided into four levels: scrotal, inguinal, pelvic, and lumbar. At the scrotal level, many small testicular veins constituting the pampiniform plexus showed various anastomoses with the cremasteric and vasal veins. At the inguinal and pelvic level, 4-12 and 2-8 LTVs were recognized, respectively. At the pelvic level, absence of valves was seen in 33% of the cases. At the lumbar level, 1-5 LTVs were observed and were mainly anastomosed with the retroperitoneal, ureteral, and kidney capsular veins. Absence of valves at the lumbar level was seen in 37% of the cases. In 11 cases, the valves that were present were incompetent. The presence of more than one LTV at the lumbar level indicates the necessity for attentive identification of all of the testicular veins during surgical treatment of varicocele.

The peritubular myoid cells in the testes from men with varicocele: an ultrastructural, immunohistochemical and quantitative study

Ultrastructural and some immunophenotypic features of the peritubular myoid cells of testes from normal men and from men with varicocele were studied. The seminiferous tubules were classified into five types (a-e), related to the progressive degree of sclerosis measured as thickening of the lamina propria. In normal testes only type a and b tubules were found, whereas the testes from men with varicocele showed type b-e tubules. Myoid cells in tubule types a and b showed slender cytoplasmic projections with abundant, parallel arranged microfilament bundles and electron-dense bodies. In c tubules, the myoid cells showed the same ultrastructure. The myoid cells of tubules with advanced (type d) or complete (type e) sclerosis showed irregularly outlined nuclei, scant microfilament bundles and absence of electron-dense bodies. Immunostaining of myoid cells with anti-actin antibodies was intense in types a-c tubules and scant in types d and e. Immunostaining with anti-desmin antibodies was intense in tubules types a-d, but the immunoreactive cells in types c and d tubules were irregularly shaped and distributed and were scanty in tubule type e. Immunostaining with anti-vimentin antibodies was weak in types a-c tubules and intense in types d and e tubules. Quantitative studies revealed that, with the progression of sclerosis, the numbers of both actin- and desmin-immunoreactive cells per cross-sectioned tubule, and the surface area occupied by the immunostained portion of these cells, decreases while the number of vimentin-immunoreactive cells and their immunostained surface area increases.

Testicular volume assessment in the adolescent with a varicocele

Testicular growth arrest is the main criterion for performing varicocele ligation in the adolescent population. Previous assessments concerning significant size discrepancy range from 0.5 to 5 cm.3, a 10-fold difference. We prospectively assessed testicular size in 22 male adolescents (ages 9 to 19 years) with varicoceles, and compared testicular volume as measured by ultrasound and Prader orchidometer in 19 of these patients. The accuracy of ultrasound for this purpose was evaluated by blinded ultrasonic measurements of models of known volume and a standard deviation of +/- 1.6 cm.3 was found. Using a size discrepancy of greater than 2 cm.3 as the criterion for growth arrest, 4 of 17 patients (24%) with growth arrest would have been missed with the Prader orchidometer alone. Testicular volumetric assessment by ultrasound accurately measured volumetric differences of greater than 2 cm.3 and can be used to determine growth arrest in the male adolescent with a varicocele.

Surgical repair of secondary right varicocele in rats with primary left varicocele: effects on fertility, testicular temperature, spermatogenesis, and sperm maturation

To evaluate whether or not dilation of the right testicular vein is a constant finding in animals with left varicocele and to illustrate its contribution to the detrimental effect of a left varicocele on the right testis, an experimental varicocele model was produced in 40 rats. Ten other rats had a sham operation (group A). Seven weeks after the operation, all 50 rats underwent laparotomy and dilation of both testicular veins was seen in 23 rats, which were randomly assigned to group B (n = 11) and group C (n = 12). One week later, groups A and C underwent sham ligation of the right testicular vein, whereas group B rats underwent resection of this vein. At 84 days after the initial operation, group C rats showed a significant reduction in right epididymal sperm content, motility, and fertilizing capacity, right testicular weight, and right testicular vs. intraabdominal temperature difference when compared with groups A and B. Since surgical repair of the secondary right varicocele improved all the parameters indicating the harmful consequences of the primary left varicocele on the right testis, it appears that dilation of the right testicular vein contributes to the detrimental effect of a left varicocele on the right testis.

Does hydrocele affect later fertility?

The purpose of this study was to investigate the prognosis for fertility in children with hydrocele. Our results show that hydrocele seems to be more of a symptom than an actual pathological entity. It occurs both with an open and a closed processus vaginalis. Bilateral hydrocele seems to be a rare occurrence, mostly affecting infants or children under 1 year of age. Hydrocele on its own seems to have no direct effect on later fertility. In the presence of certain associated pathological findings, however, the testes are significantly altered. Children with hydrocele and pathological findings are significantly older than hydrocele patients with no associated pathology. As a practical recommendation, hydrocele does not require immediate surgery. In the presence of hydrocele and certain associated pathology, however, surgery makes good sense.

Deoxyribonucleic acid polymerase activity in the testes of infertile men with varicocele

Activities of deoxyribonucleic acid (DNA) polymerase alpha, beta, and gamma were measured in extracts of testicular biopsy specimen obtained from 37 cases of male infertility with left varicocele and compared with those of 6 normal controls. It was observed that levels of DNA polymerase alpha, beta, and gamma were significantly lower in infertile men than normal controls on both sides of testes. Among three DNA polymerases, the level of DNA polymerase beta activity well correlated with the histological findings (Johnsen's score), i.e., the extent of differentiation of germinal cells. DNA polymerase beta activity appeared to be the lowest in the patients whose sperm density was less than 5 X 10(6)/ml. On the other hand, no correlation was apparent between levels of DNA polymerases and other clinical parameters, e.g., testicular volume, sperm motility, grade of varicocele, and serum hormone levels. These results suggest that the combined decrease in the DNA polymerase activities may be one of the factors that have deleterious effects on spermatogenesis in varicocele patients.

The effects of unilateral, experimental varicocele are not mediated through the ipsilateral testis

Unilateral varicocele has been associated with diminished male fertility in humans and with bilateral physiologic and histologic changes in the testis of humans and laboratory animals. In particular, left varicocele in Sprague-Dawley rats results in bilateral increases in testicular temperature and blood flow. The mechanism by which unilateral varicocele can cause testicular changes is not known. The purpose of the present study was to determine whether or not the presence of either the ipsilateral or contralateral testicle is necessary for these effects of the varicocele to occur in the opposite testis. Varicoceles were created in adult, male rats by partial constriction of the left renal vein. Bilateral testicular blood flow was measured by a radiolabelled microsphere distribution technique and testicular temperature was taken with a needle probe thermometer. Right or left orchiectomies were performed on selected animals at the time of surgery to establish the unilateral left varicocele. Animals were studied 30 days after surgery. Mean testicular blood flow was significantly increased (P less than 0.01) in all animals having a left varicocele when compared with animals not having a varicocele regardless of whether a unilateral orchiectomy was performed. Likewise, the mean difference between intraabdominal temperature and intratesticular temperature (delta T) was significantly decreased in all groups of animals having varicoceles when compared with groups without varicoceles whether or not an orchiectomy had been performed. Thus, the studied bilateral effects of left-sided, experimental varicocele in the rat are not dependent upon the presence of a left testicle.

Quantitative evaluation of Leydig cells in testicular biopsies of men with varicocele

A quantitative analysis of Leydig cells was performed in 23 testicular biopsies of men with left varicocele and sperm count ranging from zero to 95,000 sperm/mm3. The oligozoospermic patients had more Leydig cells and higher FSH and LH serum levels than the patient group with more than 10,000 sperm/mm3. The Leydig cell density appeared tightly correlated (p less than 0.01) with the serum level of LH. In oligozoospermic subjects, an altered Leydig cell function could trigger an increased LH secretion; this seems likely to be responsible for the stimulation of interstitial cells resulting in an exaggerated recruitment of mature Leydig cells from their precursors. The comparative analysis of left and right testes failed to show differences in Leydig cell density and spermatogenesis in normozoospermic and oligozoospermic patients. This suggests that the two testes are equally involved by a possible, although unknown, detrimental effect of left side varicocele.

Obstruction of the tubuli recti and ductuli efferentes by dilated veins in the testes of men with varicocele and its possible role in causing atrophy of the seminiferous tubules

Hormone measurements, spermiograms and testicular biopsies studies were performed in young with varicocele. In addition, the testes and epididymides of 27 adults with varicocele were obtained from autopsies. Light and electron microscopic examination of biopsy and autopsy specimens revealed two types of lesions in testes with varicocele: 1) a diffuse lesion consisting of abnormal spermatozoa and spermatid morphology and sloughing of immature spermatozoa and spermatid; 2) focal lesion, distributed irregularly throughout the testicular parenchyma, affecting several small groups of seminiferous tubules. Each of these groups corresponded to a testicular lobule and showed different degrees of tubular atrophy, so that the focal lesions were distributed in a mosaic pattern. The testicular interstitium showed dilated veins and venules, and progressive collagenization. Some testes showed dilated veins in the rete testis, which compressed several tubuli recti and caused tubular atrophy in the seminiferous tubules opening into these tubuli recti. Other testes showed dilated young veins among the ductuli efferentes, and the rete testis channels appeared to be dilated. Among the different etiological mechanisms which have been suggested to for testicular lesions in varicocele, tubular obstruction at the level of either the tubuli recti or the ductuli efferentes might be responsible for lesions leading to testicular atrophy.

Spermatic vein ligation in varicocele: prognosis and associated male and female infertility factors

The fertility outcome of 129 spermatic vein ligations with good postoperative anatomic results is analyzed. For each couple, specific attention was also directed to other infertility factors. The study analyzes four groups: group I, 55 patients with varicocele only; group II, 16 patients with varicocele and prostatovesiculitis; group III, 16 patients with varicocele and a severe degree of testicular failure; and group IV, 42 patients with a varicocele only and associated female infertility factors. In each group, the pregnancy rate within 6 to 24 months after the operation was recorded. The control subjects were 36 patients with varicocele only who had declined or postponed intervention for 6 months. The best results were obtained in group I. Sperm motility improved following ligation and was associated with a greater percentage of pregnancies within a shorter period: 51% and 62% within 6 and 12 months, respectively, as compared with the control group (14% within 6 months). The prostatic disease required additional treatment for a longer period, but results similar to those of group I were eventually obtained (50% pregnancy rate). With testicular failure or female infertility factors, the prognosis worsened (31% overall pregnancy rate).

Studies of the human testis. XVI. Evaluation of multiple indexes of testicular function in relation to advanced age, idiopathic oligospermia, or varicocele

Testicular function was evaluated by morphologic and biochemical methods in 11 infertile men with idiopathic oligospermia, 12 men with varicocele, and 14 elderly men. The results indicate the presence of two separate subgroups with idiopathic oligospermia with distinct endocrine and morphologic parameters and suggest the involvement of different pathogenetic factors for testicular disorders among these four groups. Biochemical indexes provide further confirmation of the validity of the Leydig cell cluster index (number of Leydig cell clusters per tubular section) as a useful evaluation guide. The results support the importance of combined studies of circulating hormones and testicular histologic features in providing insight into spermatogenic disorders. Recognition of etiologic diversity is an essential basis for further efforts to delineate and apply current or new hormonal techniques for therapy.

Ultrastructural surface characteristics of seminiferous tubules from men with varicocele

Testicular biopsies were obtained from 40 otherwise healthy men with diagnosed varicocele and processed for scanning electron microscopy. Testis biopsies from two men with scrotal pain served as control. The seminiferous epithelium was variably affected, ranging from what appeared to be essentially normal to severely altered. In tubules in which normal cellular associations were compromised, the surface anatomy of the tubule epithelium was distorted, adluminal sertoli cell cytoplasm was truncated and there was an apparent displacement, reduction in number and, in some extreme cases, absence, of germ cells. Visualization of the varicocele-affected seminiferous epithelium by the scanning electron microscope reveals more fully the extent and three-dimensional character of adluminal compartment dissolution and reconfirms our four stage classification of seminiferous tubules in this pathology.

Morphological findings in varicocele: an ultrastructural study of 30 bilateral testicular biopsies

A systematic study of a series of thirty bilateral biopsies of testes was performed using electron microscopy. Observations showed how frequently there were bilateral changes within the Sertoli cells. These included a sometimes extensive vacuolization of the endoplasmic reticulum which may cause germ cells to exfoliate. Bilateral vascular lesions including modifications of the capillary endothelium which becomes thick and rich in pinocytotic vesicles and arteriolar spasms with an increase in number of microfilaments in the endothelial cells were constantly observed.

Influence of surgically induced varicocele on testicular blood flow, temperature, and histology in adult rats and dogs

Varicocele had been repeatedly implicated as a cause of infertility in selected men, although neither a causal relationship nor a mechanism has been documented. The purpose of this investigation was to create a varicocele model in animals and to study the subsequent alterations in testicular physiology. Secondary dilatation of the left internal spermatic vein was achieved either by partial ligation of the left renal vein in rats and dogs or by surgical destruction of the valve of the left testicular vein in a second group of dogs. 1 mo after partial ligation in the rats and 3 mo after partial ligation or valve destruction in the dogs, testicular blood flow was measured using Strontium 85 (SR-85)-labeled microspheres (15 +/- 1.1 micrometer). Intratesticular temperature was measured with a Bailey needle probe thermometer and biopsies were obtained for histologic sections. Mean testicular blood flow in milliliters per minute per 100 g was significantly greater in the partially ligated rats; right testis control 26 +/- 2, left testis control 24 +/- 2 compared to right testis experimental 35 +/- 3, left testis experimental 35 +/- 4 (p less than 0.02). Dogs undergoing either partial vein ligation or valve destruction showed similar increases in mean testicular blood flow; right testis control 8 +/- 1, left testis control 8 +/- 1 vs. right testis experimental 16 +/- 3, left testis experimental 18 +/- 4 (p less than 0.01). The mean difference between intratesticular and intraperitoneal temperature in control rats was significantly higher (4.02 +/- 0.25 degrees C right testis, 3.77 +/- 0.14 degrees C left testis), than rats who underwent partial vein ligation (right testis 2.14 +/- 0.09 degrees C, left testis 2.34 +/- 0.12 degrees C) (p less than 0.001). Control dogs also had a significantly higher mean difference between intratesticular and rectal temperatures; (right testis control 3.61 +/- 0.42 degrees C, left testis control 3.60 +/- 0.40 degrees C) than the partially ligated or valve destruction dogs (right testis 2.31 +/- 0.17 degrees C, left testis 2.67 +/- 0.32 degrees C) (p less than 0.05). In addition, histologic evaluation revealed abnormalities in spermatogenesis in some of the animals. Thus, venous dilatation secondary to partial vein ligation or testicular vein valve obliteration is followed by large bilateral increases in testicular blood flow in these two species. A consequence of this increased flow is an elevation in bilateral testicular temperature, which it is postulated, leads to impaired spermatogenesis in some of the animals. In selected men varicocele may impair spermatogenesis by a similar physiologic mechanism.

Varicocelectomy and male fertility: comparison of semen quality and recurrence of varicocele following varicocelectomy by two techniques

Two hundred thirty-eight infertile men aged between 20 and 50 years suffering from left varicocele underwent ligation of the internal spermatic vein. The patients were operated on using Ivanissevich technique IT (210 patients) or the Bernardi technique BT (28 patients). In the BT group recurrences were found in 7.1% as against 28% in the IT group. The low rate of recurrence found in the BT group might be due to the fact that the patients were under local anaesthesia and collaborated with the surgeon. Varicocelectomy was followed by significant improvement in sperm quality 3 to 9 months after operation. Improvement among the fertile men was more rapid than among the infertile men. Sperm concentration improved significantly in 50% of the cases. Sperm motility improved in 37% of the cases, while morphology improved only in 29% of the cases. Sperm vitality was identical in response to that of motility. Varioocelectomy did not cause any change in the seminal plasma constituents (volume, pH, fructose). Improvement in sperm quality was identical in the IT and BT groups, as was the impregnation rate. 94 couples reported pregnancies 39.5%), which occurred within 2 years after operation (12 +/- 1.5 months mean +/- SEM). No correlation was found between size of varicocele and improvement in sperm quality and fertilizing capacity.

Testicular abnormalities of the subfertile male

Evaluation of 48 cases of male infertility included testicular biopsy. The histologic classification included normal spermatogenesis (normal or abnormal supporting tissue, maturation arrest (spermatocyte or spermatid stage), hypospermatogenesis, Klinefelter's syndrome and Sertoli-cell-only syndrome. No diagnostic advantage was found in bilateral over unilateral testicular biopsies. Clinical presentation of the patient was correlated with histologic classification: 1) 4 of 13 azoospermic cases had normal spermatogenesis, suggesting post-testicular obstruction, 2) severe oligospermic cases (1 X 10(6) sperm per ml.) had spermatogenic abnormalities and 3) only 1 of 8 mild oligospermic cases (10 to 20 X 10(6) per ml.) had abnormalities of spermatogenesis. The histologic pattern in patients with varicocele seemed consistent with hypospermatogenesis in 9 of 13 cases studied. Testicular biopsy may be useful in the diagnosis of reversible post-testicular obstruction in some azoospermic patients. In addition, some patients with severe oligospermia may find an advantage of increased accuracy of diagnostic counseling based on histologic information. Testicular biopsy in cases of moderate oligospermia may be useful as investigational information in determining histologic patterns that may be responsive to certain modes of therapy. Histologic information obtained in cases of mild oligospermia was not sufficient to provide indication for testicular biopsy in mild oligospermic patients.

Improvement of semen and pregnancy rate after ligation and division of the internal spermatic vein: fact or fiction?

Male partners with left-sided varicoceles of 96 infertile couples were studied. Fifty-one patients were submitted to ligation of the testicular veins and 45 individuals were randomised as controls. During an observation period of 53 months (range 36 to 74 months) we found no statiscally significant improvement in the semen crude variables, the morphology or the progressive motility in the series of men submitted to surgery. The pregnancy rate was lower in those who had an excision of varicocelle.

Quantitative analysis of the seminiferous epithelium in human testicular biopsies, and the relation of spermatogenesis to sperm density

Quantitative analysis of the seminiferous epithelium was performed in bilateral testicular biopsy specimens from 14 patients with sperm counts ranging from 0 to 89 million/ml. All Sertoli cells and germ cells within each seminiferous tubule cross-section were counted in all biopsies. Results were expressed either as number of cells per unit length of seminiferous tubule circumference or as number of cells per Sertoli cell. Results were correlated with sperm count (millions per milliliter), total sperm count (millions per ejaculate), and age. A significant correlation between sperm density and germ cell counts was demonstrated. Coefficients of correlation were higher when results were expressed per unit of tubular wall length than when expressed per Sertoli cell. In men with sperm counts below 5 million/ml the number of germ cells in the biopsy was lower than in men with higher sperm counts. Spermiogenesis appeared to be most affected. In this group of patients an adverse effect of age on spermatogenesis was noted.