The influence of clinical and subclinical varicocele on testicular volume

Practical Clinical and Diagnostic Pathway for the Investigation of the Infertile Couple

Capsule

This expert opinion summarizes current knowledge on risk factors for infertility and identifies a practical clinical and diagnostic approach for the male and female partners of an infertile couple aimed to improve the investigation and management of fertility problems.

Background

Infertility represents an important and growing health problem affecting up to 16% of couples worldwide. In most cases, male, female, or combined factor can be identified, and different causes or risk factors have been related to this condition. However, there are no standardized guidelines on the clinical-diagnostic approach of infertile couples and the recommendations concerning infertility are sometimes lacking, incomplete, or problematic to apply.

Objective

The aim of this work is to provide an appropriate clinical and diagnostic pathway for infertile couples designed by a multidisciplinary-team of experts. The rationale is based on the history and physical examination and then oriented on the basis of initial investigations. This approach could be applied in order to reduce variation in practice and to improve the investigation and management of fertility problems.

Methods

Prominent Italian experts of the main specialties committed in the ART procedures, including gynecologists, andrologists, embryologists, biologists, geneticists, oncologists, and microbiologists, called "InfertilItaly group", used available evidence to develop this expert position.

Outcomes

Starting from the individuation of the principal risk factors that may influence the fertility of females and males and both genders, the work group identified most appropriate procedures using a gradual approach to both partners aimed to obtain a precise diagnosis and the most effective therapeutic option, reducing invasive and occasionally redundant procedures.

Conclusions

This expert position provides current knowledge on risk factors and suggests a diagnostic workflow of infertile couples. By using this step-by-step approach, health care workers involved in ART, may individuate a practical clinical management of infertile couples shared by experts.

Role of total motile sperm count in the evaluation of young men with bilateral subclinical varicocele and asthenospermia

INTRODUCTION

In comparison to its clinical analogue, the subclinical varicocele represents a questionable entity and specific guidelines for the optimal management are lacking. In our previous study of patients with subclinical varicocele, we showed that bilateral condition is associated with risk of dyspermia. In the present study, we evaluated the risk of deterioration of semen quality in men with bilateral disease and impaired motility according to WHO criteria.

MATERIALS AND METHODS

Men with bilateral subclinical varicocele, not desiring fatherhood at the time of presentation, were included in study. During initial evaluation, the number of Total Motile Sperm Count (TMSC) was calculated and the patients' age, total testicular volume (TTV), maximum venous size and mean resistive index (RI) of the intratesticular arteries were recorded. We classified the participants in five classes according to the TMSC reading: class A-: TMSC < 5 x 106, class A: TMSC between 5-10 x 106, class B: TMSC between 10-15 x 106, class C: TMSC between 15-20 x 106, and class D: TMSC > 20 x 106 per ejaculate. The participants were seen after 6 months for a repeat spermiogram and physical examination. If clinical varicocele was diagnosed or a new abnormality in the spermiogram was noted, the participants were excluded from the study. The remaining patients were allocated to two groups according to the repeat TMSC reading: patients sub-classified into a lower class (group 1), and patients remaining at the same class (group 2). A comparative analysis was performed between two groups.

RESULTS

Nineteen men were included. Nine patients were subclassified (group 1). Three patients moved to A- class (< 5 x 106). Ten patients remained in the same class having no deterioration (group 2). Comparing the two groups, no statistically significant difference was recognized for age, TTV, maximum venous size on both sides, and mean RI (p > 0.05). However, the initial reading for TMSC was 14.57 x 106 in group 1, and 22.84 x 106 in group 2, respectively. This difference was statistically significant (p < 0.05). Additionally, in a paired analysis there was a significant difference in TMSC after 6 months (p < 0.05), too. Summary Conclusions: Young men with bilateral varicocele and asthenospermia seem to be at risk of deterioration in their semen quality after a follow-up of 6 months. The measurement of TMSC can unmask patients at risk, whereas men with the lowest readings seem to be at highest risk for deterioration. The possibility of a worsening sperm quality should be considered in the appropriate clinical context.

Ultrasound evaluation of varicoceles: systematic literature review and rationale of the ESUR-SPIWG Guidelines and Recommendations

Although often asymptomatic and detected incidentally, varicocele is a relatively common problem in patients who seek medical attention for infertility problems. Ultrasound (US) is the imaging modality of choice for evaluation, but there is no consensus on the diagnostic criteria, classification, and examination technique. In view of this uncertainty, the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) undertook a systematic review of the available literature on this topic, to use as the basis for evidence-based guidelines and recommendations. This paper provides the results of the systematic review on which guidelines were constructed.

Effect of varicocelectomy on fertility. Indications, techniques and results

We define varicocele as the dilation of the veins that make up the pampiniform plexus, which is made up of three branches, the internal spermatic, deferential and external spermatic. The World Health Organization (WHO) has determined that varicocele is an important cause of male infertility. This has been acknowledged by several studies that have shown this cause-effect relationship. Varicocele does not always generate infertility. In fact, many patients with varicocele are fertile, decreasing their percentage in the progression of the pathology and the association with other factors such as tobacco, marijuana or endocrine disorders (diabetes or hypothyroidism). Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (WHO). SURGICAL THERAPEUTICS: Surgery is indicated in cases of grade 3 varicocele (when seen through the scrotal skin and palpable as a 'bag of worms' without Valsalva maneuver), cases of atrophy or growth arrest with volume differences of more than 2cm³ between testes, when accompanied by pain and alterations in the spermiogram in young patients. CONCLUSION: The presence of varicocele determines the performance of varicocelectomy, with the inguinal approach in its three branches being the approach of preference. The laparoscopic approach will be used in specific cases.

Comparison of outcomes in intrauterine insemination, in vitro fertilisation and intracytoplasmic sperm injection in men with and without varicocele

Objectives: To investigate the differences in clinical pregnancy, miscarriage, and live birth rates when male partners were diagnosed with a varicocele and to compare these outcomes to those without and study the outcomes based on the grade of varicocele. Methods: The retrospective study was based on a cohort of consecutive infertile couples undergoing assisted reproductive technology (ART) at the Reproductive Center of Shandong Provincial Hospital affiliated to the Shandong University during the period between January 2017 and December 2018. A total of 4203 couples comprised of men with and without varicocele undergoing the first ART cycle (1501 intrauterine inseminations (IUI), 1623 in vitro fertilisations (IVF) and 1079 intracytoplasmic sperm injections (ICSI)) were included. Semen parameters and ART outcomes were determined. Results: ICSI (26.5%) originated from men with a significant lower level in sperm concentration and motility but with a strict normal morphology had a higher prevalence of varicocele than men undergoing IUI (20.7%) and IVF (18.1%). In IUI, the odds ratios (ORs) for pregnancy and live birth were significantly lower for couples in men diagnosed with grades 1 or 2 varicocele as compared to those for men with grade 3 varicocele. In IVF, ORs for live birth where men were diagnosed with grades 1 or 2 varicocele were also lower than those for men with grade 3,whereas a higher miscarriage rate was found when men had grades 1 or 2 varicocele than when men had grade 3. However, for ICSI, no significant outcomes were found in grades 1, 2 or 3 varicocele versus the no varicocele group. Conclusions: The increasing grade of varicocele was negatively associated with sperm parameters and can alter the outcome of further IUI/IVF.

Bilateral disease and intratesticular haemodynamics as markers of dyspermia in patients with subclinical varicocele: A prospective study

Objective: To study scrotal ultrasonographic characteristics in patients with subclinical varicocele (SV) and investigate their relationship with semen parameters.

Patients and methods: In all, 56 men with SV were recruited and divided into two groups, according to their semen characteristics. Group A, comprised 34 men with normal semen analysis; and Group B, comprised 22 men who carried at least one abnormality, regarding sperm concentration, motility and morphology. Between the two groups we compared: age; body mass index (BMI); semen pH and semen volume; total testicular volume (TTV); maximal vein diameter (MVD) and degree of reflux; mean values of peak-systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) of the intratesticular arteries; whether bilateral SV; and serum testosterone and follicle-stimulating hormone (FSH) levels.

Results: Asthenospermia was present in all patients in Group B; 10 patients had asthenospermia only, six patients were astheno-oligospermic and six patients had astheno-oligo-teratospermia. Age, BMI, semen pH and volume, TTV, MVD and degree of reflux did not differ significantly between the two groups (P > 0.05). However, EDV, PSV and RI were significantly different (P < 0.05). Bilateral SV was significantly more frequent in patients in Group B (P < 0.05). Finally, FSH was elevated in Group B (P < 0.05), whereas testosterone was normal in both groups, albeit significantly lower in men with abnormal semen analyses (P < 0.05).

Conclusion: Classic ultrasonographic characteristics in men with SV, such as venous size or degree of reflux, were insufficient to distinguish patients with abnormal semen analysis. However, bilateral disease and intratesticular haemodynamics differed significantly in patients with SV and abnormal semen analysis.

Abbreviations: BMI: body mass index; CDU: colour Doppler ultrasonography; EDV: end-diastolic velocity; MVD: maximal vein diameter; PSV: peak-systolic velocity; RI: resistive index; SV: subclinical varicocele; TTV: total testicular volume; US: ultrasonography

Cut-off values of the Johnsen score and Copenhagen index as histopathological prognostic factors for postoperative semen quality in selected infertile patients undergoing microsurgical correction of bilateral subclinical varicocele

Background

It remains challenging to determine which individuals are likely to benefit from microsurgical correction of subclinical varicocele, as basic semen parameters often do not improve postoperatively. We aimed to develop an easily accessible tool for prognostic stratification of infertile men indicated for microsurgical correction of bilateral subclinical varicocele characterized by prolonged and clear venous reflux and no other cause for infertility.

Methods

We retrospectively analyzed the testicular biopsy, seminal analysis, and ultrasound evaluation records of 20 men managed between 2006 and 2014. Subclinical varicocele was diagnosed through bilateral testicular palpation and auscultation of venous reflux using a Doppler stethoscope, with confirmation on color Doppler sonography. We conducted receiver operating characteristic curve analysis to identify the optimal combinations of cut-offs for the Johnsen score, Copenhagen index, and testicular volume defining histological patterns with positive prognostic value for improved postoperatively reproductive capacity.

Results

Positive prognostic value was noted for the following combinations of parameters: (I) Johnsen score >8.2 in the left testicle and right testicular volume >12.8 mL predicted improved sperm concentration; (II) Johnsen score >8.2 and Copenhagen index digit II <2.5 bilaterally predicted improved total sperm motility; (III) Johnsen score >9.1 and Copenhagen index digit III <1.5 bilaterally predicted improved progressive sperm motility; (IV) Johnsen score >7.9 and right testicular volume >13.6 mL predicted improved sperm morphology.

Conclusions

Johnsen score and Copenhagen index as histopathological prognostic factors can be easily obtained upon evaluation of testicular biopsy specimens and can be simple and reliable tool to establish a more realistic prognosis for reproductive capacity in men who undergo microsurgical correction of subclinical varicocele with no other detectable cause for infertility.

Changes in Inflammatory Cytokines Accompany Deregulation of Claudin-11, Resulting in Inter-Sertoli Tight Junctions in Varicocele Rat Testes

PURPOSE

To elucidate the changes that occur in the blood-testis barrier during varicocele we examined changes in Cldn11 (claudin-11), an element of the blood-testis barrier, as well as steroidogenesis and proinflammatory cytokines in a model of varicocele rat testes.

MATERIALS AND METHODS

Male rats with experimentally induced varicocele were sacrificed 4 weeks after operation. Testicular histology and blood testosterone concentrations were examined. The expression of tight junctions, steroidogenic enzymes, apoptosis and immune cell markers, and proinflammatory cytokines in the testes were evaluated by reverse transcriptase-polymerase chain reaction, Western blot and immunohistochemistry.

RESULTS

Weight and Johnsen scores of varicocele testes were lower than those of normal testes. mRNA expression of Bad and Bax increased whereas Bcl-xl and Bcl2 mRNA decreased in varicocele testes compared to controls. Although blood testosterone did not change, Leydig cell 3βHsd immunoreactivity, testicular 3βHsd6 and 17βHsd3 mRNA were significantly decreased in varicocele testes. Cldn11 mRNA and protein levels in varicocele testes were higher than in normal testes together with altered expression of Ocln, Zo1 and N-cadherin mRNA. Cldn11 immunoreactivity appeared as wavy strands at the periphery of the seminiferous epithelium in normal testes but was frequently found in the Sertoli cell cytoplasm in varicocele testes. In varicocele testes Tnfα, Il1α, Il6, Cd45, Cd3g and Cd3d mRNA was increased.

CONCLUSIONS

An increase in proinflammatory cytokines might be responsible for deregulation of Cldn11 in the Sertoli cells in varicocele testes, leading to alterations in the permeability of the blood-testis barrier and immunological barriers to normal spermatogenesis.

The dilemma of adolescent varicocele

Adolescent varicocele is associated with ipsilateral testicular hypotrophy and the concern for future infertility. A testicular size discrepancy greater than 15-20 % between left and right testicle is an indication for treatment to allow catch-up growth in the hope of preventing a future decline in fertility. Some authors advocate for a period of watchful waiting, as normal testicular growth may occur asymmetrically. We review the current literature to highlight some controversies and challenges in management.

The investigation of correlation between semen analysis parameters and intraparenchymal testicular spectral Doppler indices in patients with clinical varicocele

OBJECTIVES

Our aim was to evaluate the effect of clinical varicocele on testicular microcirculation measured by spectral Doppler analysis and investigate the correlation between Doppler ultrasonographic findings and semen parameters.

METHODS

Fifty patients who received a diagnosis of clinical varicocele in the Urology Department of our university hospital were enrolled in this prospective study. Varicocele grades were determined according to sonographic parameters, and a scrotal vein with a diameter of 2.5 mm or greater on color Doppler ultrasonography was included in the study. Spectral Doppler measurements of testicular arteries (peak systolic [PSV]/end-diastolic velocity [EDV], resistivity index [RI], pulsatility index [PI]) were measured from capsular and intratesticular branches of testicular arteries. All the patients were also assessed by semen analysis.

RESULTS

Mean age was 29.08 ± 5.42 years (range, 18-45 years). Among the whole study population, 22 men had isolated left varicocele, and 28 had bilateral varicoceles. No statistically significant correlation was found between the Doppler parameters: RI, PI, and EDV, and semen analysis parameters: count, motility, volume, and morphology. On the other hand, both in unilateral and bilateral varicocele cases, PSV was found to be significantly correlated with sperm count (P < 0.05).

CONCLUSIONS

Spectral Doppler analysis can provide valuable information as a noninvasive method to assess the hemodynamic changes and testicular microcirculation status in cases of clinical varicocele. However, RI, PI, and EDV values of capsular and intraparenchymal branches of testicular arteries may not be used as indicators of semen parameter deterioration. Hopefully, PSV measurement may give more conclusive data to predict sperm count. In addition, the cutoff value for this index has to be determined for future studies.

Analysis of testicular-internal spermatic vein variation and the recreation of varicocoele in a Sprague-Dawley rat model

Many laboratories tried to recreate the varicocoele model have met with varied success. To recreate a consistent varicocoele model by exploring the anatomic variability of the testicular-spermatic venous system in Sprague-Dawley (SD) rats. Seventy-two sexually mature SD male rats were randomly divided into three groups containing 24 rats per group. Partial ligation of the left renal vein and internal spermatic vein (ISV) communicating branches to common iliac vein and ISV communicating branches ligation (RVISVCBCIV) or partial ligation of the left renal vein and ISV communicating branches ligation (RVISVCB). The results showed that the mean diameter of the left ISV was significantly increased in the RVISVCBCIV group compared with the control and RVISVCB groups (p < 0.001). Using ISV as the reference, the sensitivity of varicocoele was 71.43%, and the specificity was 80%. In addition, the positive predictive value was 83.33%, and the negative predictive value was 66.67%. Sperm count, motility, Johnsen score and the spermatogenic cell density were lower in the RVISVCBCIV group compared with the control (p < 0.01). The apoptotic index was higher in the RVISVCBCIV group compared with control groups (p < 0.01). The RVISVCBCIV provides a more effective method for establishing a varicocoele-induced model.

The great debate: varicocele treatment and impact on fertility

OBJECTIVE

To evaluate the current literature on the impact and potential mechanisms of varicocele repair on male fertility.

DESIGN

Pertinent articles were identified through computer PubMed search on varicocele repair and male factor infertility. References of selected articles were hand searched for additional citations.

CONCLUSION(S)

Varicocele repair has been shown to reverse a spectrum of effects contributing to men with impaired fertility. Clinical studies on the intervention have illustrated variable effects on postoperative sperm parameters and pregnancy rates (PR). Studies with conflicting results suffer from a significant number of confounding variables such as variable repair technique or lack of controls. Additional studies are warranted on the role of modern microsurgical varicocelectomy given the improvements in assisted reproductive technologies (ART).

Subclinical varicocele in the pediatric age group

PURPOSE

This study was designed to assess the natural history of subclinical varicocele in the pediatric age group.

MATERIALS AND METHODS

We conducted a school screening for varicocele in 2,107 children 10 to 16 years old, performing clinical examination and venous Doppler study. A total of 354 boys (16.8%) without clinically detectable varicocele had venous testicular reflux during a Valsalva maneuver. Of these children 36 (a 10% sample) were selected randomly and followed annually for 4 years, with assessment of testicular volume (ultrasound values), degree of varicocele according to the Dubin and Amelar classification, and Doppler findings according to the Hirsh testicular Doppler classification. The control group consisted of 20 children selected randomly from the same population, who did not have a varicocele and had a normal Doppler study. Fisher's exact test was used with a significance value at p <0.05.

RESULTS

Mean age of the 36 children at the first assessment was 12.8 years (SD 1.7). Two boys (5.5%) had spontaneous resolution of testicular venous reflux within 2 years, and in 24 (67%) the subclinical varicocele did not change. The remaining 10 children (28%) had a clinically detectable varicocele, which was grade I in 1 patient, grade II in 7 and grade III in 2. Of these patients 1 had associated left testicular hypoplasia greater than 20%. During the 4-year period there were no clinically detectable varicoceles in the control group (p = 0.01).

CONCLUSIONS

The proportion of children with subclinical varicocele progressing to a clinically detectable form of the condition was 28% (95% CI 14 to 45) during a 4-year period. We suggest that children with subclinical varicocele require long-term followup.

Beneficial effect of microsurgical varicocelectomy is superior for men with bilateral versus unilateral repair

PURPOSE

Varicocele represents the most common correctable cause of male infertility, and most reports indicate that varicocelectomy has a beneficial effect on male fertility and pregnancy outcome. Little is known about the differential effect of bilateral, compared to unilateral varicocelectomy, on male fertility potential.

MATERIALS AND METHODS

A total of 369 consecutive varicocelectomies were performed for male factor infertility between July 1996 and July 2002. The outcomes measured include postoperative changes in semen parameters, pregnancy rates (assisted and unassisted) and use of assisted reproductive technology (intrauterine insemination and in vitro fertilization with intracytoplasmic sperm injection).

RESULTS

There were 157 men who underwent bilateral and 212 who underwent unilateral left varicocelectomy. Both groups had comparable male and female ages, and baseline semen parameters. Semen parameters improved significantly after surgery in the bilateral and unilateral groups. Moreover, the improvement in percent motility was significantly greater in the bilateral compared to the unilateral group (8.0% +/- 1.7% compared to 4.4% +/- 1.5% improvement, respectively, p <0.01). In addition, the spontaneous pregnancy rate was significantly higher in the bilateral compared to the unilateral group (49% vs 36%, respectively, p <0.05). Assisted reproductive technology was comparable in the unilateral and bilateral groups (64% vs 51%, respectively, p >0.05).

CONCLUSIONS

Our data indicate that bilateral varicocelectomy (for clinically palpable bilateral varicoceles) is associated with a significantly greater improvement in sperm quality (motility) and male fertility potential than unilateral varicocelectomy. The greater improvement in semen parameters and pregnancy outcome associated with bilateral varicocelectomy support the concept of a detrimental dose-effect of varicocele on male fertility potential.

Tasks of surgical andrology in current interdisciplinary reproductive medicine

Although the controversy about varicocele treatment options and their benefit has not been resolved, evidence is increasing that a cautious use of varicocele surgery contributes to effective management of male factor subfertility. Moreover, timely varicocele treatment might be an equally valuable prevention of later subfertility as early treatment of cryptorchidism. In reconstructive surgery of the ductal system, a more frequent use of tubulovasostomy can prevent initial failure. Furthermore, the cryopreservation of spermatic fluid for intracytoplasmic sperm injection can obviate a repeat procedure, if patency is not reached with surgery. The surgical andrologist is also the 'retriever' of sperm cells for assisted reproduction in cases of irreparable damage of the male reproductive organs. Efforts to delimit critically the indications and the results of the different techniques with large multicentre and interdisciplinary studies should be emphasized. Finally, it is encouraging that andrology does not rely solely on the successes and possibilities of assisted reproduction, but continues to inquire into the causes of male subfertility (e.g. by implementing immunohistochemical techniques into clinical research).

Is it worthwhile to operate on subclinical right varicocele in patients with grade II-III varicocele in the left testicle?

PURPOSE

To determine whether repair of subclinical varicoceles in the right testicle results in significant seminal improvement in patients with clinical left varicocele.

METHODS

Patients were divided into two groups: Group I (unilateral varicocelectomy) and Group II (bilateral varicocelectomy-subclinical left varicocele). The mean sperm concentration before treatment was higher in Group I (21.01 +/- 19.1) compared to Group II (5.7 +/- 10.7) (p = 0.04).

RESULTS

An increase in volume was detected in the left testicle of patients in Group I (17 +/- 7.9 vs. 22.81 +/- 8.2; p = 0.04) and in the right testicle of patients in Group II (18.4 +/- 6.2 vs. 22.3 +/- 6.5; p = 0.04). Although the mean postoperative sperm concentration in Group I increased slightly (25.7 +/- 22.8), the mean sperm concentration in Group II increased significantly (30.32 +/- 9.8; p = 0.03). Pregnancy rate was higher in Group II (66.7%) compared to Group I (33.3%).

CONCLUSIONS

Even a small, subclinical unrepaired varicocele continues to have a detrimental effect on bilateral testis function in a patient with grade II-III left varicocele.

Relationship between the number of veins ligated in a varicocelectomy with testicular volume, hormonal levels and semen parameters outcome

PURPOSE

Correlate semen analysis, hormones, and testicular volume with the number of veins ligated.

METHODS

Patients were divided into three groups: Group 1 (< or = 5 veins), Group 2 (6-10 veins), and Group 3 (> 10 veins). We evaluated testicular volume, hormonal levels, sperm concentration, and motility before and after the surgical procedure.

RESULTS

In Group 1, even though there was an improvement in both testicular volume and sperm concentration; testosterone levels and sperm motility did not improve with surgery. In Group 2, no changes were detected in the both testicular volumes, in sperm concentration, motility, and testosterone levels. In Group 3, an improvement was seen in the right testicle volume, testosterone levels, and sperm concentration. Follicle-stimulating hormone levels decreased following the surgical procedure in all groups.

CONCLUSION

Patients with more than 10 ligated veins have better chances to improve sperm concentration. FSH levels decreased in all groups of patients.

Loss of testicular volume associated with intratesticular varicocele

Intratesticular varicocele is a rare entity and its clinical significance is not well established. We report a case of left-sided intratesticular varicocele associated with a significant reduction in left testicular volume at follow up. This association has not been previously reported. Incidentally, our patient is also the youngest case reported in the literature to date.

Intratesticular arterial resistance and testicular volume in infertile men with subclinical varicocele

PURPOSE

The aim of this study was to evaluate whether intratesticular arterial resistance and testicular volume differed between infertile men with subclinical varicoceles and infertile men without varicoceles.

MATERIALS AND METHODS

Fifty-eight infertile men were examined by gray-scale and color Doppler sonography for presence of varicocele, testicular volume, and arterial resistance. For men in the study group, mean testicular volume and resistance index (RI) in testes with varicoceles were compared with those in the contralateral testis by the paired t-test; statistical analyses between the study and control groups were performed by independent t-tests.

RESULTS

Twenty-seven men had left-sided varicoceles (96% of which were subclinical), and 31 infertile men without varicoceles served as controls. Mean volumes of the right and left testes of study subjects were 14.8 ml and 14.6 ml, respectively, and in controls were 14.2 ml and 13.6 ml, respectively. Mean RI values for the right and left testes of study subjects were 0.61 and 0.58, respectively, and in controls were 0.61 and 0.58, respectively. There were no statistically significant differences in volume or RI, either between the right and left testes within patient groups or between the control and study groups' combined mean values. While the mean intertesticular volume differences for the study and control groups were 2.2 ml and 3.4 ml, respectively, the mean intertesticular RI differences were 0.04 and 0.07, respectively. These values also did not differ significantly between the 2 groups.

CONCLUSIONS

Subclinical varicocele is not associated with ipsilateral testicular atrophy, and does not affect the intratesticular arterial RI.

Does the gonadotropin-releasing hormone stimulation test predict clinical outcomes after microsurgical varicocelectomy?

OBJECTIVES

To examine the predictive value of the gonadotropin-releasing hormone (GnRH) stimulation test in a large cohort of infertile men undergoing varicocelectomy.

METHODS

We examined the records of 144 consecutive infertile couples in whom the man underwent microsurgical varicocelectomy between September 1998 and December 2002. All men underwent a GnRH stimulation test before surgery. Data on the preoperative and postoperative semen parameters, pregnancy outcome, and follicle-stimulating hormone (FSH) and luteinizing hormone increase after GnRH stimulation were recorded.

RESULTS

The mean (+/-SE) sperm concentration and motility 6 months after varicocelectomy were significantly greater than the preoperative values (25.3 +/- 2.4 versus 19.7 +/- 2.1 x 10(6)/mL and 29.2% +/- 1.4% versus 25.3% +/- 1.3%, respectively, P <0.05). Overall, 28% of the couples achieved a spontaneous pregnancy at a mean of 22 months of follow-up. The median elevation in the FSH and luteinizing hormone value 60 minutes after GnRH administration was 1.8 and 5.6 times the baseline level, respectively. No statistically significant relationship was found between the FSH or LH response to GnRH stimulation and improvement in the semen parameters or positive pregnancy outcome in our population.

CONCLUSIONS

Our data showed that the FSH response to bolus GnRH stimulation does not predict improvement in semen parameters or unassisted pregnancy outcome in couples in whom the man undergoes varicocelectomy (for treatment of varicocele). The study was the largest of its type and sufficiently powered to validate these findings. The results indicate that the bolus GnRH stimulation test is of no clinical value in the treatment of infertile men with varicoceles.

Effect of adult microsurgical varicocelectomy on testicular volume

OBJECTIVES

To re-examine the potential influence of varicocelectomy on testicular volume using scrotal ultrasonography, because it has been reported that total testicular volume (assessed by physical examination) increases after adult varicocele ligation.

METHODS

A retrospective review of the testicular volume and semen parameters of 61 men who underwent microsurgical varicocelectomy between 1996 and 1998 was performed. Ultrasound-derived testicular volumes and total motile sperm counts were compared before varicocelectomy and at a mean of 7.2 months postoperatively.

RESULTS

Bilateral varicocelectomy was performed in 22 men; 39 men underwent a left-sided procedure only. Overall, no significant change was found in the mean total testicular volume after varicocelectomy compared with preoperatively (24.0 versus 23.9 mL, respectively; P = 0.74). Similarly, the testicular volumes did not change significantly after left or bilateral varicocelectomy (P >0.05). Overall, the mean total motile sperm count increased significantly after varicocelectomy (17. 9 to 25.4, P = 0.05).

CONCLUSIONS

This was the first study to examine the effect of adult varicocelectomy on testicular volume using ultrasound-derived measurements of volume. Unlike previous findings, our data suggest that although adult varicocelectomy improves semen quality in most infertile men, it does not result in a significant increase in testicular volume.

Improvement of sperm count and motility after ligation of varicoceles detected with colour Doppler ultrasonography

The debate regarding the efficacy of varicocele ligation for improvement of semen parameters and pregnancy rates is ongoing. In addition, no consensus exists as to the benefit of treatment of subclinical varicoceles. The aim of this study was to investigate, retrospectively, the effect of high ligation of both subclinical and clinical varicoceles on sperm count and motility. The value of several factors from history-taking and physical examination for the prediction of successful varicocelectomy was analysed. A total of 139 patients, operated on for a unilateral varicocele on the left side, were studied. Varicoceles were subclinical in 73 patients, based on colour Doppler ultrasonography, and 66 varicoceles were clinical, based on palpation in addition to ultrasonography. Comparison of semen parameters before and after surgery revealed a significant improvement. The median sperm count increased from 10.0 to 14.7, and from 18.2 to 28.6 million/ejaculate, in patients with subclinical and clinical varicoceles, respectively (p < 0.001). The percentage improvement in median sperm count in subclinical varicoceles was not statistically different from the improvement in clinical varicoceles. Mean progressive motility improved significantly after ligation (p < 0.001). The improvement in motility in subclinical varicoceles, from 16 to 23%, was significantly larger than the 24 to 27% improvement in clinical varicoceles. The increase in sperm count was related positively to testicular volume before surgery (p < 0.05). The increase in sperm motility was significantly lower in patients with a history of cryptorchidism (n = 22, p < 0.05). The present data show that ligation of varicoceles detected using Doppler ultrasonography, whether palpable or not, results in an increase in sperm concentration and motility.