Age is a significant predictor of early and late improvement in semen parameters after microsurgical varicocele repair

Does age matter? Impact of age on testicular function and pregnancy outcomes following microsurgical varicocelectomy in patients with grade 3 varicocele

Objective

To evaluate the effects of age on semen and hormonal parameters following microsurgical varicocelectomy among patients with grade 3 varicocele, and to compare fertility outcomes between younger (<40 years) and older (≥40 years) men.

Methods

Retrospective cohort study of infertile patients with clinical left grade 3 varicocele who underwent microsurgical subinguinal varicocelectomy (MV). Patients meeting the inclusion criteria (N = 550) were divided into two groups based on their age at the time of MV: <40 (n = 441) and ≥40 years (n = 109). Preoperative semen analysis and hormonal profiles were collected, and follow-up data including pregnancy outcomes were gathered at 3 and 6 months post-surgery.

Results

Post-surgery, the younger group showed significant improvements in sperm count and total motility (p < 0.001 for each) as well as progressive motility (p = 0.005), while older men exhibited a significant increase in progressive motility (p = 0.002). For each group, there were no significant changes in hormonal levels post-surgery. Comparative analysis across the two age groups showed no significant differences in the postoperative extent of semen improvements or pregnancy.

Conclusion

MV is a viable option for older infertile patients as it is for younger infertile men with grade 3 varicocele, and both groups can achieve similarly high rates of pregnancy outcomes.

Prediction of semen analysis parameter improvement after varicocoelectomy using 1 H NMR-based metabonomics assays

BACKGROUND

Varicocoele is the most common correctable cause of male infertility; however, predicting varicocoelectomy outcomes is difficult. "Omics" techniques have been increasingly used to develop new diagnostic and prognostics tools for several male infertility causes, and could be applied to study varicocoele.

OBJECTIVES

The objective is to create metabolomics models capable of segregating men who improved semen analysis (SA) parameters or achieved natural pregnancy after microsurgical varicocoelectomy (MV) from those who did not, using hydrogen-1 nuclear magnetic resonance (1 H NMR) spectra of seminal plasma of pre-operative samples.

MATERIAL AND METHODS

We recruited 29 infertile men with palpable varicocoele. 1 H NMR spectra of seminal plasma were obtained from pre-operative samples and used to create metabonomics models. Improvement was defined as an increase in the total motile progressive sperm count (TMC) of the post-operative SA when compared to the baseline, and pregnancy was assessed for 24 months after MV.

RESULTS

Using linear discriminant analysis (LDA), we created a model that discriminated the men who improved SA from those who did not with accuracy of 93.1%. Another model segregated men who achieved natural pregnancy from men who did not. We identified seven metabolites that were important for group segregation: caprylate, isoleucine, N-acetyltyrosine, carnitine, N-acetylcarnitine, creatine, and threonine.

DISCUSSION

We described the use of metabonomics model to predict with high accuracy the outcomes of MV in infertile men with varicocoele. The most important metabolites for group segregation are involved in energy metabolism and oxidative stress response, highlighting the pivotal role of these mechanisms in the pathophysiology of varicocoele.

CONCLUSIONS

1 H NMR spectroscopy of seminal plasma can be used in conjunction with multivariate statistical tools to create metabonomics models useful to segregate men with varicocoele based on the reproductive outcomes of MV. These models may help counseling infertile men with varicocoele regarding their prognosis after surgery.

Jiawei Runjing Decoction Improves Spermatogenesis of Cryptozoospermia With Varicocele by Regulating the Testicular Microenvironment: Two-Center Prospective Cohort Study

Objective: The aim of the study was to explore the evidence of JWRJD in the treatment of cryptozoospermia.

Methods: A total of 162 cryptozoospermia patients with varicocele who refused to undergo surgery were included from January 2021 to December 2021. They were divided into the Jiawei Runjing Decoction group (group A), tamoxifen group (group B), and no treatment group (group C), and after the follow-up for 3 months, therapeutic effectiveness was compared. Network pharmacology was used to analyze and validate the effects and mechanisms of JWRJD.

Results: Fifty-eight patients were treated with JWRJD, 55 with tamoxifen, and 49 without any treatment. After treatment, five patients were lost: one in group A, one in group B, and three in group C. The sperm count and the decrease of FSH in group A were significantly higher, but the degree of decline in the testicular volume and the degree of vein expansion have decreased significantly, which were closely related to the testicular volume (TV) [especially changes in the left testicular volume (ΔL-TV)], citric acid (CC) and its changes (ΔCC), and the vein width (VW) [especially left spermatic vein width (L-VW) and mean vein width (M-VW) and their changes (ΔL-VW and ΔM-VW)], as well as the sperm count before the treatment (bSC), which were the significant indexes to predict the therapeutic effect, especially for patients >35 years old and with grade III varicoceles. Network pharmacological analysis verifies that it can be regulated by fluid shear stress and the atherosclerosis pathway to improve the testicular microenvironment for spermatogenesis.

Conclusion: JWRJD may promote spermatogenesis in cryptozoospermia patients with varicocele, which may be closely related to improving the testicular microenvironment, especially for >35 year olds and grade III varicocele patients.

Can preoperative inflammatory markers predict the success of varicocelectomy?

The aim of this study was to evaluate the effect of inflammation on the success of varicocelectomy by using some inflammatory markers. Adult male patients aged ≥18 years who were evaluated for infertility, had abnormal parameters in at least two preoperative semen analyses and underwent subinguinal microscopic varicocelectomy were retrospectively evaluated. The patients were divided into two groups; those showing improvement in semen parameters were determined as Group A and those without improvement as Group B and compared with each other. A total of 102 patients were included in this study. Group A contained 32 (31.4%) patients while Group B had 70 (68.6%) patients. Monocyte/lymphocyte ratio (MLR) and neutrophil/lymphocyte ratio (NLR) were found to be statistically significantly higher in Group B (p = 0.014 and p = 0.028 respectively). Although preoperative sperm concentration and total motile sperm count were higher in Group B, postoperative all semen parameters were significantly higher in Group A. The cutoff points that were determined using the Youden test were <2.02 for NLR (AUC = 0.636, CI = 0.519-0.754; p = 0.028) and <0.22 for MLR (AUC = 0.652, CI = 0.531-0.773; p = 0.014). Pre-varicocelectomy low NLR and MLR values were found to be significant parameters in predicting the success of the surgery.

Predictors of microsurgical varicocelectomy efficacy in male infertility treatment: critical assessment and systematization

In this review, we tried to systematize all the evidence (from PubMed [MEDLINE], Scopus, Cochrane Library, EBSCO, Embase, and Google Scholar) from 1993 to 2021 on the predictors of microsurgical varicocelectomy efficacy in male infertility treatment. Regarding the outcomes of varicocele repair, we considered semen improvement and pregnancy and analyzed them separately. Based on the 2011 Oxford CEBM Levels of Evidence, we assigned a score to each trial that studied the role of the predictor. We systematized the studied predictors based on the total points, which were, in turn, calculated based on the number and quality of studies that confirmed or rejected the studied predictor as significant, into three levels of significance: predictors of high, moderate, and low clinical significance. Preoperative total motile sperm count (TMSC) coupled with sperm concentration can be a significant predictor of semen improvement and pregnancy after varicocelectomy. In addition, for semen improvement alone, scrotal Doppler ultrasound (DUS) parameters, sperm DNA fragmentation index (DFI), and bilateral varicocelectomy are reliable predictors of microsurgical varicocelectomy efficacy.

Prediction of reproductive function recovery after microsurgical varicocelectomy in men from infertile couples: Clinical and laboratory predictors

The objective was to reveal predictors for fertility recovery after varicocelectomy in subfertile men. This retrospective study recruited 93 men with clinical varicocele and pathozoospermia who underwent microsurgical varicocelectomy. Stepwise discriminant analysis was performed to identify predictors of spontaneous pregnancy (SP) after surgery. 'Clinically significant improvement' (CSI) following varicocelectomy was defined as an increase in total progressively motile sperm count (TPMSC) by at least 12.5 million (calculated from WHO-2010 reference values). 52% of patients showed CSI, and 28% reported SP after surgery. Patients who reported SP (group II), compared to that remained infertile (group I), were younger (27.3 ± 2.9 versus 30.2 ± 4.2 years; p < .01), had less infertility period (24.1 ± 14.0 versus 44.4 ± 32.9 months; p < .05) and had initially higher TPMSC (median (25% -75%) = 34 (11-67) versus 9.5 (0-33) mln; p < .05). The stepwise discriminant analysis showed that male age (coefficient value = -0.157), total sperm motility (0.024) and postoperative increase in TPMSC (0.010) were the significant predictors of SP. The predictive ability, sensitivity and specificity of the discriminant function were 84%, 87%, 76% respectively. This algorithm can be recommended after varicocelectomy in decision-making on natural conception or the ART protocols usage.

Can preoperative gonadotropin and testosterone levels predict the success of varicocelectomy?

We examined the effects of preoperative hormonal values on varicocelectomy success. A total of 136 patients who underwent varicocelectomy for infertility in our clinic were analysed retrospectively. Improvement in semen quality was defined as >50% increase in post-operative total motile sperm count (TMSC) in those with preoperative TMSC >5 million and at least 100% increase in those with <5 million. The patients were divided into two groups as benefiting from the treatment (Group A) and no benefits (Group B). The best cut-off value for follicle-stimulating hormone (FSH) and the luteinising hormone/testosterone ratio (LTR) that can predict varicocelectomy success were 7.01 and 0.016 with an area under the curve of 0.844 and 0.856 respectively. The highest sensitivities and specificities of FSH and LTR were 0.845 and 0.788 and 0.821 and 0.846 respectively. Binary logistic regression analysis showed FSH (odds ratio [OR]: 3.7; p < .001) and LTR (OR: 5.2; p < .001) as independent predictive factors in predicting varicocelectomy success. Our study demonstrated that low FSH (7.01 IU/L) and LTR (<.016) can be a useful preoperative predictive tool to help identify men who benefit most from varicocelectomy in infertile patients with varicocele.

Clinical factors affecting semen improvement after microsurgical subinguinal varicocelectomy: which subfertile patients benefit from surgery?

Background

The exact mechanism of varicocele-related infertility is still elusive, therefore, the current challenges for its management lie in determining which patients stand to benefit most from surgical correction. The authors aimed to assess the clinical factors affecting semen improvement after left microsurgical subinguinal varicocelectomy (MSV) in relation to patient age, ultrasound varicocele grading (USVG), and presence of a right subclinical varicocele (RSV).

Methods

From 2010 to 2017 a total of 228 infertile patients underwent left MSV for clinical varicocele. Descriptive statistics were used to describe the cohort and verify the surgical benefit in terms of semen improvement, in addition, subsets of patients were selected according to clinical covariates. Logistic regression modeling was applied to evaluate the presence of RSV, operative time, age, and USVG as explanatory variables.

Results

Sperm concentration (SC), progressive sperm motility (PSM), and normal sperm morphology (NSM) increased significantly after surgery (p = 0.002; p = 0.011; p = 0.024; respectively). Mean SC improved after MSV in ⩾35 year-old patients and the grade 3 USVG group (p = 0.01; p = 0.02; respectively). Logistic regression modeling showed a that the probability of SC improvement was 76% lower in subjects presenting RSV (p = 0.011). In addition, patients with a grade 3 USVG presented a three-times greater probability of SC improvement compared with patients with a lower USVG (p = 0.035). In addition, older patients showed a greater probability of SC improvement after MSV (p = 0.041).

Conclusions

MSV is an effective varicocele-related infertility treatment that should also be offered to older patients. In addition, patients with a higher USVG benefit from surgery. In infertile men with an RSV in association with a left clinical disease, a bilateral varicocele repair should be considered.

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.

Varicoceles affect semen quality of infertile men in Southern China: A cross-sectional study of 5447 cases

The association of varicoceles with infertility is well established, but the exact effect of varicoceles on semen quality among patients with infertility is still poorly known. The study aimed to examine the prevalence of varicoceles among Chinese men with infertility and to examine the factors associated with semen quality.This was a cross-sectional study of 5447 male patients treated for infertility at the Affiliated Hospital of Guangdong Medical University from October 2012 to December 2015. The patients were divided on the basis of the presence of varicoceles. Examinations of the amount of semen and sperm morphology were performed according to seminal parameter detection methods recommended by the World Health Organization.Patients with varicoceles (n = 1429/5447, 26.2%) were slightly younger (P = .046), and had smaller testis (P = .019), higher frequency of abnormal epididymis (P < .001), slightly shorter infertility duration (P = .046), and lower frequency of smokers (P = .012). There was no difference in the distribution of occupations (P = .777). Using multiple linear regression analysis, varicoceles were shown to be independently associated with semen volume [B = -0.153, 95% confidence interval (95% CI): -0.245 to -0.062, P = .001], sperm concentration (B = 9.633, 95% CI: 7.152-12.114, P < .001), proportion of sperms with normal morphology (B = 0.951, 95% CI: 0.623-1.278, P < .001), motility (B = 3.835, 95% CI: 2.675, 4.995, P < .001), total sperm count (B = 22.481, 95% CI: 13.333-31.629, P < .001), and forward movement sperm count (B = 15.553, 95% CI: 9.777-21.329, P < .001). Varicoceles were present in 26% of Chinese male patients with infertility.Varicoceles were independently associated with sperm volume, sperm concentration, proportion of sperms with normal morphology, motility, total sperm count, and forward movement sperm count.

Semen parameters and pregnancy rates after microsurgical varicocelectomy in primary versus secondary infertile men

In a prospective study, the outcomes of microsurgical varicocelectomy in men with primary versus secondary infertility were compared. Ninety-two infertile men with a varicocele were included. They were classified into those with primary infertility (n = 57) and secondary infertility (n = 35). Clinical data, semen parameters and scrotal ultrasound finding were available for all patients and microsurgical varicocelectomy was performed on all of them. Spontaneous pregnancy rates and improvement in semen parameters in those men with primary versus secondary infertility were recorded 1 year after surgery. Preoperatively, there was no significant difference in the mean semen parameters in both groups (p > 0.05) and the mean semen parameters showed no significant difference between men with primary and secondary infertility. After microsurgical varicocelectomy, the mean semen parameters improved significantly in both group (p < 0.05 for each), but there were no significant difference in mean semen parameters between men with primary versus secondary infertility (p > 0.05 for each). After adjustment for patient and partner ages, the pregnancy rate at the end of the follow-up period did not significantly differ between the primary (24/57, 42.1%) and secondary (11/35, 31.4%) infertility group (Pearson's Chi-squared = 1.05). We concluded from this study that semen parameters and pregnancy rates after microsurgical varicocelectomy were similar between men with primary and secondary infertility.