Low plasma testosterone in varicocele patients with impotence and male infertility

Association between varicocele and hypogonadism, or erectile dysfunction: A systematic review and meta-analysis

OBJECTIVE

To assess the association between varicocele and hypogonadism, or erectile dysfunction.

METHODS

We searched MEDLINE, EMBASE, LILACS, CENTRAL, and other sources. We included cohort, case-control, and cross-sectional studies. The primary outcome was the association between varicocele and hypogonadism, or erectile dysfunction, and the secondary outcome included semen analysis. We assessed the risk of bias with the Newcastle-Ottawa Scale. We performed statistical analysis in Review Manager 5.3 and reported information about the Odds Ratio (OR) with a 95% confidence interval. We produced a forest plot for the primary outcome.

RESULTS

We included ten studies in qualitative analysis and six studies in quantitative analysis. Most of the cross-sectional studies showed a low risk of bias, not so for the two case-control studies, which represented a high risk of bias. Most of the reports described a correlation between having varicocele and presenting low testosterone levels: the meta-analysis showed that there is a significant association between varicocele and hypogonadism (OR 3.27 95% CI 1.23 to 8.68). Regarding varicocele and erectile, only one study showed a significant difference in erectile function in comparison to varicocele patients and men without varicocele.

CONCLUSION

There is an association between varicocele presence and hypogonadism, although more studies are needed. Besides, not much is reported about an association between varicocele and erectile dysfunction, but impairment can occur through hormone disturbances.

Effects of Varicocele Repair on Testicular Endocrine Function: A Systematic Review and Meta-Analysis

PURPOSE

The objective of this manuscript is to assess the effect of varicocele repair (VR) in patients with clinical varicoceles on serum total testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and inhibin B serum levels.

MATERIALS AND METHODS

The study was performed in compliance with the Meta-Analysis and Systematic Reviews of Observational Studies (MOOSE) guidelines and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). All eligible studies were selected following the PICOS (Population, Intervention, Comparison/Comparator, Outcomes, Study design) model. The values of each outcome measured after VR were compared to the before parameters and, when available, to the values on patients with unrepaired varicocele, and to those of healthy controls with no varicocele. For total testosterone, the values were sub-analyzed based on the mean total testosterone levels before VR (<300 ng/dL or >300 ng/dL), the fertility status, the time of follow-up and the technique used for VR.

RESULTS

From a total of 460 abstracts retrieved, 48 articles were included in our meta-analysis. Serum total testosterone levels were significantly higher after VR compared to both pre-treatment levels (mean difference [MD] 82.45 ng/dL, 95% confidence interval [CI]: 64.14-100.76; p<0.00001) and to the levels of patients with unrepaired varicocele (MD 91.64 ng/dL, 95% CI: 62.30-120.99; p<0.00001). They did not differ from the levels of healthy controls with no varicocele (MD -22.01 ng/dL, 95% CI: -68.59-24.58; p=0.35). The increase resulted to be independent from the mean total testosterone levels before VR, fertility status, time of follow-up and type of VR. After VR, a trend toward lower serum LH levels was found compared to before values (MD -0.37 IU/L, 95% CI: -0.74-0.01; p=0.06). When compared to the levels of patients with unrepaired VR, LH levels after VR were significantly lower (MD -0.96 IU/L, 95% CI: -1.56 to -0.35; p=0.002). LH levels were not significantly higher than healthy men without varicocele (MD 0.84 IU/L, 95% CI: -0.68-2.36; p=0.28). Patients with VR had significantly lower FSH levels compared to their pre-treatment values (MD -1.43 IU/L, 95% CI: -1.82 to -1.04; p<0.00001), and also to those of patients with non-repaired varicocele (MD -2.35 IU/L, 95% CI: -4.06 to -0.65; p=0.007). When compared to healthy controls with no varicocele, FSH levels were significantly higher (MD 2.71 IU/L, 95% CI: 1.12-4.31; p=0.0009). Lastly, after VR no significant change in inhibin B serum levels was seen compared to pre-treatment levels (MD 11.76 pg/mL, 95% CI: -3.83-27.35; p=0.14).

CONCLUSIONS

The present meta-analysis is the largest to date to assess the impact of VR on Leydig cell and Sertoli cell function using a before-after analysis for uncontrolled studies, and using data from patients with unrepaired varicoceles or healthy patients without varicocele as controls. VR was found to increase and restore to normality serum levels of total testosterone and LH. This evidence could be of value in considering the treatment of varicocele in patients with low testosterone or those who show a progressive decline in testosterone levels.

COVID-19 and varicocele: the possible overlap factors and the common therapeutic approaches

Varicocele is recognized as one of the main attributable causes of male infertility which can affect spermatogenesis by various pathophysiological mechanisms. Recent studies have identified oxidative stress and reduction in antioxidant, hyperthermia, hypoxia, hormonal dysfunction, and inflammatory conditions as major factors in the pathophysiology of varicocele, all of which have known direct associations with the coronavirus disease 2019 (COVID-19) and can significantly increase the risk of detrimental COVID-19-related outcomes. Emerging data have shown an association between COVID-19 and inflammation, overproduction of cytokine, and other pathophysiological processes. The present review, summarizes the current understanding of the pathophysiology of varicocele and investigates the potential correlation between the severity of COVID-19 and the varicocele disease. In addition, various possible treatments which can be effective in both diseases were examined. Despite numerous challenges associated with the prevalence of COVID-19 in healthcare systems in infected countries, special attention should be given to maintaining a high level of care for complex patients with a pre-existing disease such as varicocele and providing appropriate practical advice for optimal control of the COVID-19 disease. This article is protected by copyright. All rights reserved.

Efficacy of microsurgical varicocelectomy in the treatment of premature ejaculation: A protocol for systematic review and meta-analysis

INTRODUCTION

Premature ejaculation (PE) is the most common type of sexual disorder among men which comprises a great of problems. Varicocele is defined as the dilation of the pampiniform venous plexus draining the testicle. At present, selective serotonin reuptake inhibitors antidepressants, topical anesthetics, tramadol, phosphodiesterase type 5 inhibitors are the common alternative strategy to improve PE. However, these therapeutic measures have several shortcomings and side effects. Recently, the correlation between varicocele and PE has attracted the attention of some researchers. A few studies consider microsurgical varicocelectomy can be a new remedy for PE. But it is still absent enough a great deal of convincing evidence. The study will assess the effectiveness and safety of the microsurgical varicocelectomy treatment in PE patients.

METHODS AND ANALYSIS

Electronic databases including English databases (PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library) and Chinese databases (China National Knowledge Infrastructure, China Biology Medicine Database, Wanfang Database, VIP Database) will be searched from their inception to December 2020 to recognize related studies. All the randomized controlled trials of microsurgical varicocelectomy for the management of PE patients will be included. The potential outcome will include intravaginal ejaculation latency time, Chinese index of sexual function for premature ejaculation-5, visual analogue score, premature ejaculation diagnostic tool, success treatment rate, serum testosterone levels. We will conduct this study strictly according to the Cochrane Handbook for systematic reviews of interventions.

RESULTS

The current study is a protocol for systematic review and meta-analysis without results, and data analysis will be carried out after the protocol. We will share our findings in the February 28, 2021.

CONCLUSION

This systematic review will provide more evidence to assess whether microsurgical varicocelectomy is an effective intervention for patients with PE. The results will be published in a public issue journal and offer the urologists and andrologists help to make clinical decisions.

ETHICS AND DISSEMINATION

Formal ethical approval is not required in this protocol. We will collect and analyze data based on published studies, and since there are no patients involved in this study, individual privacy will not be under concerns. The results of this review will be disseminated to peer-reviewed journals or submit to related conferences.

PROTOCOL REGISTRATION NUMBER

INPLASY202060058.

Relationship of Hormonal Parameters to Sperm Production in Patients with Varicocele

Idiopathic varicocele is a one of the all too often organic causes of male infertility and may can affect hormonal and spermatogenic function of the testis. We demonstrated relationships of hormonal parameters to sperm production on follicle-stimulating hormone (FSH), (LH) and testosterone blood concentrations to sperm production. The investigations involved a total of 329 patients with varicocele, at aged from 20 to 48 years, mean age 28.76 ± 0.66 years, divided into three groups: group I – patients with varicocele dextra; group II – patients with varicocele sinistra; and group III – patients with varicocele bilateralis. We established in our investigations that in 65.35% of cases the varicocele was attended coupled by with some disorders in the fertilizing ability, included including oligospermia Gr I-II (groups I and II) in 41.33% of cases, oligospermia (Gr.II-IIIgroups II and III) in 15.5% of cases and azoospermia in 8.52% of cases. In 56.83% of cases, the low sperm concentration was attended by decreasedcoupled with reduced sperm motility and velocity. Our data did not demonstrated a statistically significant increase in blood plasma T testosterone and we noted no significant correlation between the magnitude of the change in serum androgen and improvements in sperm concentration or total sperm motility per ejaculate in patients with varicocele. No significant correlations were noted in mean blood LH and FSH concentrations in patients with varicocele and in controls group.

Varicocele and testicular function

Testicular varicocele, a dilation of the veins of the pampiniform plexus thought to increase testicular temperature via venous congestion, is commonly associated with male infertility. Significant study has clarified the negative impact of varicocele on semen parameters and more recent work has shed light on its detrimental effects on the molecular and ultrastructural features of sperm and the testicular microenvironment, as well as more clearly defined the positive impacts of treatment on couples’ fertility. The relationship between varicocele and testicular endocrine function, while known for some time based on histologic evaluation, has become more apparent in the clinical setting with a growing link between varicocele and hypogonadism. Finally, in the pediatric setting, while future study will clarify the impact of varicocele on fertility and testicular function, recent work supports a parallel effect of varicocele in adolescents and adults, suggesting a re-evaluation of current treatment approaches in light of the progressive nature of the condition and potential increased risk of future disease.

Impact of varicocelectomy on premature ejaculation in varicocele patients

In a prospective manner, we studied the effect of varicocelectomy on premature ejaculation and testicular hormonal function in patients with varicocele. Microsurgical subinguinal varicocelectomy was carried out in 73 patients with clinical varicocele associated with premature ejaculation (group 1) and compared with 56 patients without operative intervention (group 2; control). The primary efficacy variable was the mean change in the Premature Ejaculation Diagnostic Tool. The changes in International Index of Erectile Function questionnaire, total serum testosterone and testicular size were also assessed. In group 1, the Premature Ejaculation Diagnostic Tool decreased significantly after varicocelectomy, from 15.56 to 11.37 (P < 0.001), indicating improvement of premature ejaculation. Thirty patients (41.1%) showed improvement of premature ejaculation compared to 5.3% in the control group (P < 0.001). In group I, but not in group II, testosterone levels and International Index of Erectile Function values increased significantly when compared with pre-operative values (P < 0.001 and 0.040 respectively). Testicular size increased after varicocelectomy, but this increase was nonsignificant till the end of study (P = 0.054). We concluded that varicocelectomy is clearly related to improvement of premature ejaculation and testicular hormonal function in varicocele patients.

Varicocele-induced infertility: Newer insights into its pathophysiology

The association between varicoceles and male infertility has been known since the 1950s; however, the pathophysiology of the process remains uncertain. The primary proposed hypotheses involve hyperthermia, venous pressure, testicular blood flow, hormonal imbalance, toxic substances, and reactive oxygen species. It is difficult to identify a single or dominant factor, and it is likely that many of these factors contribute to the infertile phenotype seen in clinical practice. Moreover, patient lifestyle and genetic factors likely affect patient susceptibilities to the varicocele insult. While the current studies have weaknesses, they provide building blocks for futures studies into the pathophysiology of the varicocele.

Effects of varicocele on testosterone, apoptosis and expression of StAR mRNA in rat Leydig cells

The aim of this study was to explore the effects of varicocele on the morphology and function of Leydig cells in the rat testis. Forty male Sprague-Dawley rats were divided into two groups: the experimental group underwent surgery to create a left varicocele (VC), and the control group underwent a sham operation. Serum testosterone and intratesticular testosterone levels were measured using a radioimmunoassay after 4 and 8 weeks of operation. Leydig cells were studied for apoptosis and expression of steroidogenetic acute regulatory (StAR) protein mRNA levels. Serum testosterone levels declined after 4 and 8 weeks of operation but were not significant (P>0.05). However, the intratesticular testosterone levels after 8 weeks were significantly decreased compared with the control group (P<0.01). The mean apoptosis index of Leydig cells in the experimental group was significantly higher than that in the control group after 4 or 8 weeks (P<0.01). StAR mRNA levels in the Leydig cells of the experimental group were significantly lower compared to those of the control group (P<0.01). Our data show that varicocele did impair Leydig cell function by increasing apoptosis and suppressing the expression of the StAR protein.

Does varicocelectomy improve gonadal function in men with hypogonadism and infertility? Analysis of a prospective study

Varicocele in infertile males is associated with Leydig cell dysfunction and hypogonadism. The effect of varicocelectomy on serum testosterone level is not yet established. We analysed 200 heterosexual infertile men diagnosed to have clinical varicocele they were divided into two groups: group 1 (100 men) had microsurgical varicocelectomy, and group 2 (100 patients) underwent assisted reproduction procedures. All participants had semen analysis, serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and total testosterone (TT), measured both at recruitment time and 6 months later. In group 1, the mean TT level increased significantly after varicocelectomy (1.644 ± 0.029 to 2.461 ± 0.0198 ng/dL, P < 0.0001) and testicular size correlated with the mean change in TT (P = 0.001). No similar change was found in group 2. Out of the 100 patients in group 1, 78 had postoperative normalization of TT unlike only 16 men in group 2.

Impact of varicocelectomy on gonadal and erectile functions in men with hypogonadism and infertility

INTRODUCTION

Previous reports linked varicocele in infertile males with Leydig cell dysfunction and hypogonadism.

AIM

The aim of this study was to determine the impact of varicocelectomy on serum total testosterone (TT) level and erectile function in men with infertility and clinical varicocele.

METHODS

This study included 141 heterosexual infertile men diagnosed to have clinical varicocele. They were divided into two groups: group 1 (103 men), who had microsurgical varicocelectomy, and group 2 (38 patients), who decided to pursue assisted reproduction procedures. All participants completed the International Index of Erectile Function (IIEF)-5 questionnaire and underwent semen analysis. Serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and TT were measured both at recruitment time and 6 months later.

MAIN OUTCOME MEASURE

Changes in serum TT and IIEF-5 following varicocelectomy.

RESULTS

In group 1, the mean TT level increased significantly post-varicocelectomy (379.1 ± 205.8 to 450.1 ± 170.2 ng/dL, P < 0.0001). No similar change was found in group 2. Out of the 49 patients in group 1 with hypogonadism at baseline assessment (TT < 300 ng/dL), 37 (75.5%) exhibited a postoperative normalization of TT. However, only 3/15 hypogonadal men (20%) in group 2 had normal testosterone levels at the second visit. IIEF-5 scores improved significantly postoperatively in patients with hypogonadism (17.1 ± 2.6 to 19.7 ± 1.8, P < 0.001). Neither operating vein diameter 3.6 ± 0.57 mm nor testicular size 10.46 ± 3.3 mL correlated with the mean change in TT (71.1 ± 101.2 ng/dL) (r = 0.162, P = 0.183 and r = -0.077, P = 0.536, respectively).

CONCLUSIONS

Varicocele is associated with hypogonadism in some infertile patients. Varicocelectomy significantly improves serum testosterone in infertile men, especially those with hypogonadism. This improvement in TT level may be reflected in the IIEF score.

Varicocele sclerotherapy improves serum inhibin B levels and seminal parameters

The usefulness of treating varicocele in order to improve fertility is still a matter of debate. The aim of this study was to evaluate variations in seminal parameters and inhibin B concentrations in a group of males affected by varicocele and treated by percutaneous retrograde sclerotherapy in comparison with a group of patients who did not undergo varicocele treatment. Thirty-eight patients with left varicocele underwent spermatic vein phlebography and percutaneous retrograde sclerotherapy with hydroxy-polyaethoxy-dodecanol. Serum inhibin B, follicle-stimulating hormone (FSH), testosterone levels and seminal parameters (sperm concentration, motility and morphology) were performed before and 6 months after sclerotherapy. Forty patients with left varicocele who did not undergo sclerotherapy were studied as controls. A significant increase (p < 0.01) in serum inhibin B levels and a significant decrease (p < 0.05) in FSH levels were observed 6 months after treatment. Semen analysis showed a significant improvement in sperm concentration (p < 0.05) and progressive motility (p < 0.01) after treatment. In control group no significant variations in hormonal and seminal parameters were observed 6 months after the basal examination. Six months after the basal evaluation, inhibin B levels were significantly higher in treated subjects than in controls (p < 0.05) whereas FSH levels were significantly lower (p < 0.05). Sperm concentration and progressive motility were significantly increased (p < 0.05 and p < 0.001, respectively) in treated subjects in comparison with controls. In conclusion, varicocele sclerotherapy improves inhibin B levels and seminal parameters, confirming the positive effect of this treatment on spermatogenesis and Sertoli cell function.

Outpatient varicocelectomy performed under local anesthesia

AIM

To report a series of varicocelectomy performed under pure local anesthesia.

METHODS

From July 1988 to June 2003, a total of 575 patients, aged between 15 and 73 years, underwent high ligation of the internal spermatic vein for treatment of a varicocele testis under a regional block in which a precise injection of 0.8 % lidocaine solution was delivered to involved tissues after exact anatomical references were made. A 100-mm visual analog scale (VAS) was used to assess whether the pain level was acceptable.

RESULTS

The surgeries were bilateral in 52 cases, and unilateral in 523 cases. All were successfully performed on an outpatient basis except in the case of two patients, who were hospitalized because their surgeries required general anesthesia. Overall, 98.6 % (567/575) of men could go back to work by the end of the first post-operative week and only 8 (1.4 %) men reported feeling physical discomfort on the eighth day. The VAS scores varied from 11 mm to 41 mm with an average of (18.5+/-11.3) mm that was regarded as tolerable.

CONCLUSION

This study has shown varicocelectomy under local anesthesia to be possible, simple, effective, reliable and reproducible, and a safe method with minimal complications. It offers the advantages of more privacy, lower morbidity, with no notable adverse effects resulting from anesthesia, and a more rapid return to regular physical activity with minor complications.

Experimental Varicocele Induces Testicular Germ Cell Apoptosis in the Rat

PURPOSE

We evaluated the impact of experimentally created varicocele on ipsilateral and contralateral testicular germ cells in the rat.

MATERIALS AND METHODS

Experimental left varicocele was created by partial ligation of the left renal vein in 17 adult male Sprague-Dawley rats. An additional 5 rats that underwent laparotomy and renal vein handling without ligation served as sham surgical controls. Five rats that underwent no surgical or other intervention served as a control group. Rats were sacrificed 7 (5), 14 (5) or 28 (7) days following varicocele creation. Germ cell apoptosis was quantified using a TUNEL assay. The results of this assay are expressed as the number of apoptotic germ cell nuclei per seminiferous tubular cross section. The presence of apoptosis was confirmed by cellular ultrastucture evaluation using transmission electron microscopy.

RESULTS

Control and sham animals were found to have a mean of 0.05 and 0.15 apoptotic germ cells per seminiferous tubular cross section, respectively. Rats sacrificed 7, 14 and 28 days after varicocele creation were found to have 0.15, 0.23 and 0.27 apoptotic germ cells per tubule in the ipsilateral testis, and 0.14, 0.16 and 0.17 apoptotic germ cells per tubule in the contralateral testis, respectively. Compared with control animals a statistically significant increase in the number of apoptotic germ cells per tubular cross section was noted 14 days following varicocele creation in the ipsilateral testis (p <0.05).

CONCLUSIONS

The creation of experimental varicocele generated an increase in germ cell apoptosis in the ipsilateral testis at 14 days compared with control animals.

Improvement of sexual activity, pregnancy rate, and low plasma testosterone after bilateral varicocelectomy in impotence and male infertility patients

To evaluate the effects of bilateral varicocelectomy on sexual activity, testicular volumes, semen quality, and serum hormone levels in impotence and male infertility patients, 48 patients were studied from an outpatient clinic from May 1998 to March 2001. The mean age was 37+/-5.9; 16 patients were complaining of erectile dysfunction and 32 patients were complaining of male infertility. The mean duration of impotence was 3.3+/-2.4 years and for male infertility was 3.8+/-3.2 years. Sexual and reproductive history was taken for erectile dysfunction and male infertility patients. General, local examination, and laboratory investigations were done for all patients. Preoperative and postoperative testicular volumes; semen parameters, including semen volume, sperm count, and motility; and morphology and hormonal parameters, including LH and FSH, and testosterone levels were measured. All patients were followed up for 3-36 months after varicocele repair. Left and right testicular volume was improved in impotence and male infertility patients and fertility groups, but this improvement was not statistically significant (p>.25). The semen volume was significantly increased in male infertility patients and fertility group (p<.05), but there was no statistical significant difference in impotent patients (p>.25). The sperm count was improved in male infertility patients and fertility group, but this improvement was not statistically significant (p>.25), and in impotent patients there was no significant difference (p>.40). The sperm motility was very significantly increased in male infertility patients and the fertility group (p<.0005), and highly significantly increased in impotent patients (p<.005). The abnormal forms were not statistically significant in impotence and male infertility patients (p>.40), but significantly decreased in the fertility group (p<.05). Serum testosterone was very significantly increased in impotence and male infertility patients (p<.0005) and was highly significantly increased in fertility groups (p<.005). Serum FSH was improved in impotence and male infertility patients, but this improvement was not statistically significant (p>.10), and in fertility groups of male infertility patients, the results showed a statistically significant increase (p<.05). Serum LH was not statistically significant in impotence and male infertility patients (p>.10), and was significantly increased in fertility groups (p<.05). The improvement of sexual activity was 50-75%, the pregnancy rate for their partners was 37% and increased plasma testosterone levels over a period of 3 years of follow-up after varicocele repair.

Varicocele: current concepts in pathophysiology, diagnosis, and treatment

Although significant advances have been made in the understanding of varicoceles, a clear pathophysiologic mechanism remains elusive. Most likely, a varicocele is the result of a multifactorial process. Appreciation of the complex venous drainage of the testis remains a key to maximizing the chances for treatment success. Likewise, the advent of microsurgical repair has minimized complications. Fortunately, times have improved since the early nineteenth century, when the French surgeon Delpech (1772-1832) was killed by a disgruntled patient on whom he had performed a varicocele repair.