Significance of serum inhibin B concentration for evaluating improvement in spermatogenesis after varicocelectomy

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.

Predictive parameters of the efficacy of varicocele repair: a review

ABSTRACT

Varicocele has a prevalence of 15% in the population and represents a primary cause of infertility in 40% of cases and a secondary cause in approximately 80% of cases. It is considered the major correctable cause of male infertility. Despite its high prevalence in the infertile population, a large number of patients with varicocele do not experience reproductive difficulties. For this reason, it is still highly debated which parameters could be used to predict which patients with varicocele will be most likely to benefit from its repair. The main international and European guidelines state that treatment should only be considered in infertile patients with abnormal sperm quality. However, these guidelines do not help physicians to identify which of these patients may benefit from the treatment. Therefore, this narrative review collects the evidence in the literature on the usefulness of some factors as predictors of improvement, highlighting how some of them may be effective in an initial selection of patients to be treated, while others are promising but further studies are needed. Finally, a brief consideration on the possible role of artificial intelligence is proposed.

Effects of Varicocele Surgical Repair on Serum Hormone and Inhibin B Levels for Patients With Varicocele: A Systematic Review and Meta-Analysis

Varicocele surgical repair can improve the function of the testis for patients with varicocele. We carried out a systematic review and meta-analysis to assess the effects of varicocele surgical repair on serum hormones and inhibin B levels in patients with varicocele. A literature search was performed in August 2022, and no language or geographic region restrictions were applied. The search included the following databases: PubMed, Embase, and Medline. A literature review was performed to identify all published clinical trials assessing serum hormone and inhibin B levels before and after varicocele surgical repair. The reference lists of retrieved studies were also investigated. A systematic review and meta-analysis were conducted. Eight articles were selected from 162 articles, including 452 patients. The combined analysis showed that after surgical treatment, mean serum testosterone, inhibin B, and sperm concentration levels increased compared with preoperative levels (p < .05). After surgical treatment, mean serum follicle-stimulating hormon (FSH), and Luteinizing hormone (LH) levels decreased compared with preoperative levels (p < .05). This meta-analysis demonstrates that varicocele surgical repair can improve testicular function, increase serum testosterone, and inhibin B levels and decrease serum FSH and LH levels in patients with varicocele. This might be related to the improvement of infertility. A large-scale multicenter randomized controlled study is needed for further confirmation.

Retrograde sclerotherapy of male varicocele with veno-venous shunts - incidence and management: a single-centre experience

OBJECTIVES

The aim of our study is to compare the incidence of veno-venous shunts in male varicocele and evaluate the possibility to exclude them with manual compression or/and scrotal ligation in order to carry out the procedure of retrograde sclero-embolization.

METHODS

In our retrospective study, all patients undergone retrograde sclerotherapy for varicocele in our Interventional Radiology Unit in the last four years were evaluated. Collaterals toward other venous shunts were identified and how many and which patients would be able to complete the procedure safely were considered.

RESULTS

Of the 91 patients, as many as 22 (i.e., 24.17%) patients presented anatomical variants, consisting on shunting into left iliac vein (9 [9.89%]), lumbar left veins (3 [3.29%]), right iliac vein (1 [1.09%]), both iliac veins (1 [1.09%]), left femoral vein (1 [1.09%]) or a more proximal portion of the ISV itself without shunting (3 [3.29%]). Patients with duplication could benefit from a more distal injection in order to prevent back-flow; of the 19 left, nine successfully underwent sclerotherapy with manual compression or/and scrotal ligation, whereas in 10 flow through the collaterals could not be interrupted and patients were demanded for surgery.

CONCLUSIONS

Many patients with abnormal communications between the internal spermatic vein and the iliac veins (that is, shunts towards the iliac veins) may as well undergo retrograde sclerotherapy safely if compression/ligation is applied.

ADVANCES IN KNOWLEDGE

No large previous study highlighted the impact of veno-venous shunts in technical feasibility of retrograde sclerotherapy of varicocele.

Novel Potency Assay for MSC Secretome-Based Treatment of Idiopathic Male Infertility Employed Leydig Cells and Revealed Vascular Endothelial Growth Factor as a Promising Potency Marker

Idiopathic male infertility is a highly prevalent diagnosis in developed countries with no specific treatment options. Although empirical medical treatment is widely used to restore male fertility, its efficacy remains limited and inconclusively proven. Therefore, the development of novel therapeutic approaches in this field is a high-priority task. Since the failure of testicular microenvironment components might be involved in the pathogenesis of idiopathic male infertility, application of mesenchymal stromal cells (MSCs) as well as the MSC secretome is worth considering. Previously, we showed that the intratesticular injection of MSCs or the MSC secretome led to the recovery of spermatogenesis at least through replenishing the testicular microenvironment and its maintenance by MSC-secreted paracrine factors. However, the clinical use of such products has been limited to single trials to date. This may be due to the lack of relevant potency tests reflecting mechanisms of action of the MSC secretome in male infertility models. Based on the presumptive MSC secretome mode of action on the testicular microenvironment, we suggest a novel approach to test the potential efficacy of the MSC secretome for idiopathic male infertility treatment. It represents a potency assay based on evaluation of testosterone production by isolated Leydig cells. We demonstrated that the MSC secretome stimulated testosterone secretion by Leydig cells in vitro. We then hypothesized that among the major factors of the MSC secretome, vascular endothelial growth factor (VEGF) could be responsible for the observed effects, which we confirmed by the revealed correlation between the extent of stimulated testosterone production and VEGF concentration in the MSC secretome. The pilot results obtained from the doxorubicin-induced male infertility murine model also indicate the important impact of VEGF in the MSC secretome’s regenerative effects. Utilizing VEGF as a surrogate factor, a novel approach to study the potency of MSC secretome-based products for idiopathic male infertility treatment is suggested. Further validation is required for its implementation into the biopharmaceutical manufacturing process.

Management of adolescent varicocele

Varicocele is defined as an abnormal dilation and tortuosity of the internal spermatic veins found within the pampiniform plexus. It is a common finding in adolescents and adult men alike, however its diagnosis in the adolescent population poses different dilemmas in regard to indications for treatment than in adults. Failed Paternity is a clear-cut indication for repair in adult men attempting to father children. In adolescents, the physicians, family and patients must consider potential for future fertility problems which may or may not actually become of concern. Assessing the degree of negative effect of the varicocele on an adolescent's testicular health can also be difficult as teenagers typically are not asked to provide semen for analysis and thus surrogate markers for testicular health such as testicular size differentials must be used. Treatment options for the adolescent varicocele are similar to options in adult populations. While risks and benefits of various techniques can be considered, the gold standard for varicocele repair in adolescents has not been clearly defined. We aim to discuss diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.

Preoperative follicle-stimulating hormone: A factor associated with semen parameter improvement after microscopic subinguinal varicocelectomy

INTRODUCTION

Currently, there exists no serum biomarker to predict patients likely to benefit from varicocelectomy. The purpose of this study was to assess the association between baseline follicle-stimulating hormone (FSH) and semen parameter changes after subinguinal microscopic varicocelectomy.

METHODS

We retrospectively reviewed all men who underwent microscopic subinguinal varicocelectomy between August 2015 and October 2018. Pre- and postoperative semen analyses were stratified per total motile sperm count (TMSC): TMSC <5, 5-9, and >9 million (based on TMSC required for in vitro fertilization, intrauterine insemination [IUI], and natural conception, respectively). Then, variables were analyzed to determine the correlation with postoperative TMSC values and upgrade in TMSC category.

RESULTS

Among the 66 men analyzed, 55 (83.3%) and 11 (16.7%) had a preoperative TMSC of <5 million and 5-9 million, respectively. A total of 33 (50%) patients upgraded in TMSC category, 26 of them achieving levels corresponding to natural conception and seven achieving those of IUI. Additionally, a significant correlation was observed between postoperative TMSC and preoperative TMSC (r=0.528; p<0.001), and preoperative FSH (r=-0.314; p=0.010). A lower preoperative FSH (odds ratio [OR] 0.82; 95% confidence interval [CI] 0.68-0.98; p=0.028) and a higher preoperative TMSC (OR 1.37; 95% CI 1.06-1.76; p=0.015) were associated with upgrade in TMSC category.

CONCLUSIONS

Lower preoperative FSH and higher TMSC are associated with improvement in TMSC category after varicocelectomy, although small sample size limited the study. FSH can be useful to identify men who are most likely to benefit from varicocele repair.

Indications and outcomes of varicocele repair

Varicoceles exert deleterious effect on testicular function. The condition has been associated with male infertility, testicular hypotrophy and pain. These comprises the common indications for varicocele repair currently. Significant improvement in semen parameters and pregnancy outcomes had been suggested by reports decades ago. However, selection of the best candidates remains an issue since not all patients respond positively to treatment. Consensus has been reached in recent decade after the publication of a series of meta-analyses. Significant improvement in pregnancy outcomes were reported in patients with clinical varicocele and abnormal semen parameters. Varicocelectomy in adolescents with testicular hypotrophy was supported by the positive implication on catch-up growth and semen parameters. However, little is known about the treatment effect of adolescence varicocelectomy on long term fertility and paternity rate. Recent studies on outcome of varicocele repair for pain consistently demonstrated a resolution rate of approximately 90% and support varicocele-associated pain as an indication for surgery. Alternate indications for varicocele repair have been proposed in recent decade. Despite the encouraging preliminary data, most studies were uncontrolled retrospective series. Although varicocelectomy may not obviate the need for assisted reproductive techniques in patients with non-obstructive azoospermia, it potentially increases sperm retrieval rate. The significant increase in serum testosterone after varicocelectomy in patients with androgen deficiency may open an alternative treatment for hypogonadism. The adjunctive role of varicocelectomy before assisted reproduction and the significant decrease in sperm DNA fragmentation after varicocele repair deserve further well-designed controlled studies.

Treating varicocele in 2018: current knowledge and treatment options

PURPOSE

Varicocele is defined as a state of varicosity and tortuosity of the pampiniform plexus around the testis caused by retrograde blood flow through the internal spermatic vein. The prevalence of clinically relevant varicocele ranges from 5 to 20% in the male population and is often associated with infertility and reduction of sperm quality. In this review, the pathophysiology and clinical aspects of varicocele are reviewed along with therapeutic options and treatment effects on sperm parameters and fertility both in adult and in pediatric/adolescent subjects.

METHODS

We conducted a Medline and a PubMed search from 1965 to 2018 to identify publications related to varicocele clinical aspects, treatment procedures and treatment outcomes. Keywords used for the search were: "varicocele", "varicocelectomy", "sclerotherapy", "male infertility", "subfertility", and "semen abnormalities".

RESULTS

Data from a large number of studies in adolescent and adult males indicate that varicocele correction improves semen parameters in the majority of patients, reducing oxidative stress and improving sperm nuclear DNA integrity either with surgical or percutaneous approach.

CONCLUSIONS

Varicocele repair seems to represent a cost-effective therapeutic option for all males (both adolescent and adults) with a clinical varicocele in the presence of testicular hypotrophy, worsening sperm alterations or infertility. On the other hand, some investigators questioned the role of varicocelectomy in the era of assisted reproduction. Thus, a better understanding of the pathophysiology of varicocele-associated male subfertility is of paramount importance to elucidating the deleterious effects of varicocele on spermatogenesis and possibly formulating new treatment strategies.

Comparison of the clinical characteristics of patients with varicocele according to the presence or absence of scrotal pain

We investigated the clinical characteristics of patients with varicocele according to the presence or absence of scrotal pain. We retrospectively reviewed the records of patients who underwent varicocelectomy. The age, body mass index, grade, laterality of varicocele, testicular volume difference, time to hospital visit, serum testosterone level and semen parameters were evaluated. A total of 954 patients were included. The painful group had lower mean age, lower BMI, higher grade of varicocele, smaller testicular volume difference and shorter time to hospital visit than the painless group. In addition, the median serum total testosterone level and total sperm count, concentration and motility were higher in the painful group than in the painless group. In multivariate analysis, there were significant differences between the two groups in age, grade of varicocele, testis volume difference, time to hospital visit, total sperm count and concentration. Patients with painful varicocele visited hospital earlier because of the pain and tended to start treatment sooner. They were also younger, had smaller testis atrophy and had higher sperm concentration, even though they had a higher grade of varicocele than patients without pain. Although scrotal pain in varicocele patients is difficult to treat, it leads to early diagnosis and treatment.

Effect of Varicocelectomy on Serum FSH and LH Levels for Patients with Varicocele: a Systematic Review and Meta-analysis

Varicocelectomy can improve the function of testicular Leydig cell for patients with varicocele. We carried out a systematic review and meta-analysis to assess effect of varicocelectomy on serum FSH and LH levels for patients with varicocele. A literature review was performed to identify all published randomized preoperation-postoperation clinical trials of assessing serum FSH and LH levels before and after varicocelectomy. The search included the following databases: PUBMED and EMBASE. The reference lists of retrieved studies were also investigated. A systematic review and meta-analysis were conducted. Five studies were selected from 149 studies, including 312 patients. The meta-analysis showed that serum FSH level (95% confidence interval 0.19-0.77, P = 0.001) and serum LH level (95% confidence interval 0.25-0.91, P = 0.0005) were higher preoperation than postoperation. Serum FSH level decreased by 0.48 ng/dL after varicocelectomy. The mean decrease of the serum FSH was from 0.1 to 4.8 ng/dL. And serum LH decreased by 0.58 ng/dL. The mean decrease of the serum LH was from 0.2 to 2.1 ng/dL. This meta-analysis proves that varicocelectomy perhaps can decrease serum FSH and LH levels in patients with varicocele. And it might be related to the improvement of the function of Leydig cell. But it remains to need a large-scale multicenter randomized controlled study to be further confirmed.

Effects of varicocelectomy on serum testosterone

Varicocele is most often surgically repaired due to male infertility, however, has recently been linked to low serum testosterone. This paper serves to review the current literature regarding varicocele and its subsequent repair on serum testosterone. Twenty-eight human studies were identified with fifteen showing improved serum testosterone after repair. The majority of the studies that demonstrated improvement had preoperative testosterone levels that were low or below normal. Additionally, multiple well-designed studies with control groups not undergoing surgical repair demonstrated significant difference between groups. This improvement was less observed in studies with normal preoperative serum testosterone. A majority of these patients studied were presenting for infertility. It remains to be determined if these findings can be reproduced in men without infertility. The findings suggest that microsurgical varicocele repair can improve serum testosterone in men with low levels preoperatively in appropriately counseled men. It remains to be seen whether varicocele repair can help prevent the development of low testosterone in the future or which patients are at risk of developing low testosterone due to varicocele.

When is a varicocele repair indicated: the dilemma of hypogonadism and erectile dysfunction?

In the past, the indications for varicocelectomy are primarily for infertility with abnormal semen parameters, testicular hypotrophy/atrophy in adolescents, and/or pain. The surgical treatment of varicocele for hypogonadism is controversial and debated. Recently, multiple reports in the literature have suggested that varicocele is associated with hypogonadism and varicocele repair can increase testosterone levels. Men with hypogonadal symptoms should have at least two serum testosterone levels. Microsurgical varicocelectomy may be beneficial for men with clinically palpable varicoceles with documented hypogonadism. In this review, we summarize the most recent literature linking varicocele to hypogonadism and sexual dysfunction and the impact of repair on serum testosterone levels. We performed a search of the published English literature. The key words used were “varicocele and hypogonadism” and “varicocele surgery and testosterone.” We included published studies after 1998. We, also, evaluated the effect of surgery on the changes in the serum testosterone level regardless of the indication for the varicocele repair.

Varicocele - a case for early intervention

Testicular varicocele, which is defined as the dilation of the veins draining the testicle, has long been associated with a detrimental effect on testicular function. Despite a lack of high-quality, prospective data, recent evidence has shed light on potential links between varicocele and male infertility and serum testosterone levels. Similarly, varicocele repair has increasingly been shown to have a beneficial impact on pregnancy rates, semen parameters, and on improving serum testosterone in adult men. Numerous studies have assessed the optimal technique for varicocele repair and the bulk of the evidence has shown the microsurgical inguinal/subinguinal approach to have the highest success rates, the lowest overall complication rates, and the lowest recurrence rates. The management of varicocele in adolescents remains a clinical conundrum, but contemporary evidence suggests early deleterious effects of varicocele on testicular function in some patients. Well-designed prospective trials are critical to delineate the true impact and role of varicocele repair on male infertility and hypogonadism in adult and adolescent men.

Serum levels of inhibin B in adolescents after varicocelelectomy: A long term follow up

Introduction

To study the impact on adult’s fertility of serum inhibin B levels in adolescent patients with idiopathic varicocele after minimally invasive surgical correction and to compare fluctuation of pituitary-testis hormonal values and testicular volumes.

Materials and Methods

A case-control study was carried out on a group adolescent patients (n=60) affected by idiopathic left varicocele (group V) and compared with control adolescents (n=40) in the Paediatric Surgery Section of Siena (from June 1993 till September 2013). Inhibin B levels and testicular volume before (T0) and after at 6 and 12 months from surgery (T1 and T2) were evaluated.

Results

A positive correlation between testicular growth at T1 and T2 (P<0.001) was found. Linear regression analysis showed a positive correlation between inhibin B levels and testicular volume (expressed as the sum of the right and left values) (P<0.0001).

Conclusions

Inhibin B levels are a valid marker for studying the effects of varicocele on the testicular function and confirm the necessity of early surgical correction for preventing the trophic testicular damage and male infertility.

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.

Beneficial effects of varicocele embolization on semen parameters

BACKGROUND

The value of varicocele repair and the latter's impact on semen parameters are still subject to debate.

METHODS

We analyse changes over time in initially abnormal sperm parameters and serum concentrations of testosterone, FSH and inhibin B after embolization treatment of males with high-grade varicocele. From 2007 to 2012, we recruited 47 male infertile patients with clinically visible left varicocele in the resting patient and at least one abnormal semen parameter. Sperm parameters and serum levels of total testosterone, FSH and inhibin B were measured prior to retrograde embolization (M0) and then 3 (M3) and 6 (M6) months afterwards.

RESULTS

At M0, the median sperm concentration was 5.78 [0.84-37.70] × 10(6)/ejaculate. The mean ± SD sperm progressive motility, vitality and percentage of normal sperm were respectively, 21.83 ± 16.48%, 61.88 ± 15.98% and 12.88 ± 7.15%. The corresponding values at M3 were significantly higher (38.75 [3.96-95] × 10(6)/ejaculate, 29.32 ± 14.21%, 69.14 ± 14.86% and 19.03 ± 11.02%, respectively). The mean percentage of spermatozoa with a thin head was significantly lower at M6 (6.35 ± 5.29%) than at M0 (14.03 ± 13.09%). The mean serum testosterone, FSH and inhibin B levels did not change significantly over time.

CONCLUSIONS

Embolization treatment in men with clinically visible left varicocele, abnormal sperm parameters and documented infertility is associated with a significant improvement in semen parameters including sperm head morphology.

Effect of surgical repair on testosterone production in infertile men with varicocele: a meta-analysis

OBJECTIVES

To determine the effect of surgical varicocele repair in improving testicular Leydig cell function as shown by increased testosterone production.

METHODS

Eligible studies were searched in Medline and the Pubmed database, and cross-referenced as of 31 May 2011 using the terms "varicocele,""testosterone" and "surgery." The database search, quality assessment and data extraction were independently carried out by two reviewers. Only studies including patients with testosterone evaluation before and after surgery were considered for the analysis. A systematic review and meta-analysis was carried out for continues variables using random effect models.

RESULTS

Out of 125 studies, a total of nine were selected, including 814 patients. The combined analysis showed that mean serum testosterone levels after surgical treatment increased by 97.48 ng/dL (95% confidence interval 43.73-151.22, P=0.0004) compared with preoperative levels.

CONCLUSIONS

Surgical treatment of varicocele significantly increases testosterone production and improves testicular Leydig cell function.

Serum inhibin B levels before and after varicocelectomy in early adolescence

BACKGROUND

Whereas no clear relationship has been observed between varicocelectomy and serum inhibin B levels in men, in adolescents comparison between inhibin B levels before and after varicocelectomy is lacking.

AIM

To evaluate the effect of varicocele surgical treatment on inhibin B levels in adolescents at the beginning of puberty compared to a group of healthy adolescents.

SUBJECTS AND METHODS

We studied 28 adolescents in Tanner 2 pubertal stage with a grade III left-sided varicocele (patients) compared to 13 age and pubertal stage-matched healthy adolescents (controls). All patients underwent blood tests to determine serum inhibin B levels before and 6 months after varicocelectomy by Palomo procedure. For comparison we investigated inhibin B levels in controls and repeated this test 6 months later. Testicular ultrasound was performed for patients only.

RESULTS

Baseline inhibin B concentrations of patients and controls were 109.90 ± 40.26 and 109.33 ± 38.34 pg/ml, respectively. No significant changes were observed in patients' inhibin B concentrations after varicocelectomy (116.00 ± 42.65 pg/ml), or in controls during the 6 months' follow-up (99.12 ± 30.09 pg/ml). Doppler examination after treatment shows a complete resolution of varicocele in all the patients without alterations in testicular parenchyma.

CONCLUSIONS

Varicocelectomy performed on adolescents at T2 pubertal stage might be useful to avoid alteration in inhibin B production and consequently in testicular function. Further studies are necessary to confirm the prognostic value of inhibin B levels and the benefit of early varicocelectomy in preserving the fertility of these adolescents.

Dynamic endocrine test of inhibin B and anti-Müllerian hormone in men with non-obstructive azoospermia

Although both serum inhibin B (Inh-B) and anti-Müllerian hormone (AMH) concentrations have been proposed as markers of spermatogenesis in men with subfertility, there are wide overlaps with fertile controls. The main aim of this study was to evaluate stimulated serum Inh-B and AMH concentrations in men with non-obstructive azoospermia (NOA). Thirty-seven men with NOA confirmed by testicular fine-needle aspiration and 17 fertile controls participated at this prospective, case-control study. All subjects underwent the Exogenous FSH SErtoli Reserve Test (EFSERT): estimation of serum Inh-B and AMH concentrations before, 24 and 48 hours after administration of 300 IU human recombinant FSH (hrFSH). Basal serum Inh-B and AMH concentrations, as well as Inh-B concentrations at 24 and 48 h were lower in men with NOA as compared to controls. No changes in Inh-B or AMH concentrations were recorded throughout the EFSERT in either men with NOA or controls nor when men with NOA were classified according to their clinical, hormonal and cytological diagnosis. Thus, stimulated serum concentrations of Inh-B and AMH, as obtained by an EFSERT, do not contribute to the diagnostic evaluation of the men with NOA, as the same information can be acquired by the basal serum concentrations of these hormones.

INHIBIN B LEVELS IN PERIPHERAL VEIN DO NOT CORRELATE WITH INHIBIN B LEVELS IN THE SPERMATIC VEIN IN ADOLESCENTS WITH VARICOCELE

This study was conducted to evaluate the inhibin B with FSH and LH levels on spermatogenesis in varicocele patients. The study group consisted of 10 adolescent with left idiopathic varicocele of grade II and III. Blood specimens were obtained from dilated spermatic vein and peripheral vein simultaneously. Peripheral samples were also collected from 7 healthy children as controls. Inhibin B was measured with ELISA inhibin B kits. FSH and LH were analyzed by radioimmunoassay techniques. The results were analyzed using Mann-Whitney U and Spearman's rank tests. A value of p < 0.05 was considered significant. Peripheral FSH, LH and inhibin B levels were the same in the study and control group (p > 0.05). Mean inbibin B levels of spermatic vein were significantly higher than the control and peripheral blood of the study groups (p < 0.05). FSH, LH, and inhibin B levels correlated poorly each other (p > 0.05). Preoperative serum inhibin B concentration could not reliably predict a response to varicocelectomy, but the increase in inhibin B levels after treatment might suggest an improvement in testicular function.

VARICOCELE LIGATION ON FREE TESTOSTERONE LEVELS IN INFERTILE MEN WITH VARICOCELE

We have analyzed the effects of varicocele ligation on free testosterone levels, and investigated the interrelationships between free testosterone and fertility. The records were retrospectively evaluated for 42 infertile patients who underwent varicocele ligation, with serum free testosterone levels, follicle stimulating hormone (FSH), lutenizing hormone (LH), testosterone, estradiol, prolactin, ejaculated volume, sperm concentration and motility before and after surgery. Serum free testosterone levels increased from 12.97+/-4.16 to 13.59+/-3.93 pg/mL, but the difference was insignificant. The differences before and after surgery of patients in sperm concentration and motility were also insignificant. However, in free testosterone increasing group, the sperm concentration and motility increased significantly, from 4.05+/-4.35 to 7.90+/-8.19 million/mL (P=0.01) and from 30.64+/-21.87% to 41.00+/-22.00%, respectively (P=0.03). The increase in serum free testosterone level by varicocele ligation results in a significant improvement in sperm concentration and motility.

Hormonal evaluation of the infertile male: has it evolved?

An endocrinologic evaluation of patients who have male-factor infertility has clearly evolved and leads to specific diagnoses and treatment strategies in a large population of infertile men. A well-considered endocrine evaluation is especially essential with the ever-growing popularity of assisted reproductive techniques and continued refinements with intracytoplasmic sperm injection.

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.

Altered serum inhibin b levels in adolescents with varicocele

BACKGROUND/PURPOSE

Different studies have evaluated testicular hormonal dysfunction in adolescent varicocele but with variable results. Recently, inhibin B has been proposed as a marker for spermatogenesis and Sertoli cell function. The aim of the present study was to study in a homogeneous cohort of adolescents inhibin B and other hormones to detect whether untreated varicocele may be associated with any modifications of these factors.

METHODS

Sixteen adolescents (mean age, 14.5 +/- 1.0 years), at Tanner stages 4 to 5 with grade II or III left-sided varicocele, underwent hormonal evaluation of inhibin B, basal testosterone, and both baseline and GnRH stimulated FSH and LH levels. Thirteen unaffected adolescents of age-matched and pubertal development were used as controls.

RESULTS

Patients with varicocele showed a significant reduction in the testicular volume of the affected side (13.3 +/- 4.1 vs 15.8 +/- 4.8 mL; P = .002) and significant reduced levels of inhibin B compared with controls (271.9 +/- 70.2 vs 327.1 +/- 34.9 pg/mL; P = .042). Inhibin B levels were significantly correlated with testes volume (r = 0.62; P = .0097). Other hormonal parameters were similar in both varicocele and control groups.

CONCLUSION

Inhibin B is reduced in adolescents with untreated varicocele, and it is positively correlated with testicular volume. This could be an early marker for Sertoli cell damage, with possible implications for spermatogenesis and could represent a new indication for varicocele repair.

Inhibin B is a better marker of spermatogenesis than other hormones in the evaluation of male factor infertility

OBJECTIVE

To assess the role of inhibin B in the evaluation of male factor infertility.

DESIGN

Prospective study.

SETTING

Reproductive endocrinology clinic.

PATIENT(S)

Seventy-five patients with infertility problems (mean age 31.2 +/- 7.5 years) and 12 controls (32.1 +/- 8.8 years) with proven fertility.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Semen analysis was performed according to World Health Organization guidelines. Testicular volume was assessed with the Prader's orchidometer. Serum levels of inhibin B (pg/mL), LH (mIU/mL), FSH (mIU/mL), prolactin (micro IU/mL), and testosterone (nmol/L) were assessed.

RESULT(S)

The mean +/- SEM inhibin B and testosterone levels were significantly lower in the patients than in the controls (inhibin B: 116.4 +/- 11.7 vs. 181.2 +/- 20.9, P=.008; testosterone: 13.6 +/- 0.9 vs. 25.1 +/- 2.9, P=.008). In general, sperm count and testicular volume in the patients were significantly and positively correlated with inhibin B (sperm count: r = 0.476, P<.0001; testicular volume, right: r = 0.57, P=.0001; left: r = 0.53, P=.0001); the inhibin B-FSH index was negatively correlated with FSH. Inhibin B was more strongly correlated with testicular volume and semen parameters than FSH. Inhibin B in the patients was negatively correlated with FSH (r = -0.723, P=.0001) and LH (r = -0.52, P=.0001) and was positively correlated with testosterone (r = 0.4, P=.0013).

CONCLUSION(S)

Inhibin B measurement is a better marker of fertility status than FSH and LH. Concentration of inhibin B in patients with infertility may provide useful information on spermatogenesis and possibly serve as a more direct marker of spermatogenesis than FSH.

Effect of age and grade on surgery for patients with varicocele

OBJECTIVES

To assess the seminal characteristics, hormonal levels, and pathologic findings in patients of various age groups with varicocele before and after ligation to establish the presence of an aging effect in patients with varicocele on those characteristics.

METHODS

The records were retrospectively evaluated for 70 infertile patients with azoospermia or oligospermia who underwent microsurgical left inguinal varicocele ligation. The mean +/- SD patient age was 33.9 +/- 5.5 years. Left varicocele was detected in 70 patients. We divided our patients into three groups according to age: group 1, 20 to 29 years old (n = 17); group 2, 30 to 39 years old (n = 41); and group 3, older than 40 years (n = 12).

RESULTS

Before ligation, no significant differences were seen among the three groups in luteinizing hormonal level, prolactin level, estradiol level, right testicular volume, semen volume, and sperm concentration and sperm motility. Significant differences were seen in the follicle-stimulating hormonal level, testosterone level, and left testicular volume. After ligation, even in group 3, the sperm concentration and motility increased from 6.38 +/- 5.47 to 13.07 +/- 9.05 million/mL (P = 0.042) and from 28.42% +/- 23.22% to 39.92% +/- 22.06%, respectively. No significantly greater degree of improvement in semen characteristics was observed between grade II and grade III after varicocele ligation.

CONCLUSIONS

The results of our study have shown that age is not a significant predictive factor of improvement in semen characteristics before ligation. It is reasonable to perform ligation to improve the semen characteristics in patients older than 40 years old.

Significance of inhibin in reproductive pathophysiology and current clinical applications

The human reproductive process is regulated by complex mechanisms that involve many organs, including the brain, gonads and endocrine system. It has been more than 70 years since the name 'inhibin' was used to describe a substance produced in the gonads that negatively regulates pituitary secretion. Inhibin B controls FSH secretion via a negative feedback mechanism. It is a glycoprotein hormone secreted by the Sertoli cells of the testis and granulosa and theca cells of the ovary. Serum inhibin B concentrations are positively related to testicular volume and sperm counts. Current understanding of inhibin physiology and pathology in the human suggests that inhibin B may be of importance as a marker of Sertoli cell function in men with infertility and as a prognostic indicator in women undergoing ovulation induction therapy. Inhibin concentrations are elevated in patients with granulosa cell tumours and in post-menopausal women with mucinous ovarian cancers. Immunoreactivity against the inhibin alpha-subunit was identified in all cases of adrenal cortical adenoma and carcinoma, and levels are suppressed in the malignant prostate disease. This article discusses the structure, regulation and clinical use of inhibin and other related substances.

Serum levels of dimeric and monomeric inhibins and the degree of seminal alteration in infertile men with varicocele

The aim of the present study was to establish the serum levels of inhibins and their relationship with the degree of seminal alteration in infertile men. Thirty-six patients with varicocele (Va) and seven non-obstructive azoospermic men (Az) were included. The Va group was divided into two subgroups: Va I (sperm concentration: >20 x 106; n = 21) and Va II (sperm concentration: < 20 x 106; n = 15). Twelve fertile men were included as a control group (Co). Semen analysis and serum follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone (T), inhibin B and Pro-alphaC levels were determined. Serum inhibin B and T levels were significantly lower and FSH and LH significantly higher in group Az when compared with the Co. Inhibin B was unable to differentiate Va I from Va II groups. However, in Va II an increase in FSH levels was observed. An inverse correlation between inhibin B and FSH, a direct correlation between inhibin B and testosterone, sperm concentration, motility and morphology were found. No such correlations were seen when only the Va group was analysed. The lack of correlation between serum levels of inhibin B, gonadotrophins, sperm concentration and seminal parameters observed in Va, adds other factor to the complex pathophysiology of varicocele. Finally, further studies are needed to elucidate if oligozoospermic patients with varicocele have also an impaired negative feed-back mechanism that regulates FSH synthesis and secretion.