Does varicocelectomy improve semen in men with azoospermia and clinically palpable varicocele?

Second chance in fertility: a comprehensive narrative review of redo micro-TESE outcomes after initial failure

ABSTRACT

When microdissection testicular sperm extraction (micro-TESE) fails, a redo procedure may be the only option for patients who want a biological child. However, there are many gaps of knowledge surrounding the procedure, which need to be addressed to help clinicians and patients make informed decisions. This review explores redo micro-TESE in the context of nonobstructive azoospermia (NOA). Literature was searched using Google Scholar, Medline, and PubMed. Search terms were "NOA" AND "second microdissection testicular sperm extractions" AND "redo microdissection testicles sperm extraction" AND "repeat microdissection testicular sperm extractions" AND "failed microdissection testicular sperm extractions" AND "salvage microdissection testicular sperm extractions". Only original articles in English were included. A total of nine articles were included, consisting of four retrospective and five prospective studies. The time gap between the first and second micro-TESE varied from 6 months to 24 months. Most of the included studies reported successful surgical sperm retrieval (SSR) in the second micro-TESE in the range of 10%-21%, except in one study where it reached 42%. It has not been presented any definitive information about the use of hormonal treatment or the benefit of varicocelectomy prior to the second micro-TESE. Patients with hypospermatogenesis and Klinefelter syndrome (KS) had the highest chance of success in redo surgery. In conclusion, redo micro-TESE following a negative procedure can lead to sperm recovery in 10%-21%. Patients with hypospermatogenesis and KS have a higher chance of success. There is no enough evidence to conclude which is the best hormonal stimulation if any before a redo surgery.

Microscopic internal spermatic-inferior epigastric vein anastomosis for treating left varicocele

OBJECTIVE

To evaluate the clinical efficacy of microscopic internal spermatic-inferior epigastric vein anastomosis in the treatment of left varicocele and compare it with microscopic spermatic vein ligation for the same condition.

METHODS

A retrospective analysis of 74 patients with left varicocele between July 2020 and July 2022 was performed. The patients were divided into two groups based on the surgical method used. Group A consisted of 37 patients who underwent microscopic internal spermatic-inferior epigastric vein anastomosis, while Group B consisted of 37 patients who underwent microscopic spermatic vein ligation. Comparison of preoperative and postoperative semen quality, reproductive hormone levels, scrotal ultrasound results, duration of surgery, length of hospital stay, postoperative recurrence rate, and occurrence of complications with a follow-up time of 12 mo between two groups.

RESULTS

Both groups showed significant improvements in semen quality and serum reproductive hormone levels. The Group A demonstrated significantly improved sperm forward motility compared to Group B, but had longer operation times and hospital stays (P < 0.05). After 1 year of follow-up, 8 partners in Group A and 6 partners in Group B achieved natural conception, with no significant difference between the two groups. There were no recurrences observed in either group during the follow-up period, and no significant statistical differences were found in other postoperative observation indicators.

CONCLUSIONS

Both microscopic internal spermatic-inferior epigastric vein anastomosis and microscopic spermatic vein ligation are effective surgical methods for treating left varicocele. Anastomosis surgery provides greater improvement in sperm motility, although it is associated with longer operation times and hospital stays.

Seminal TEX101 May Predict Seminal Sperm Recovery after Varicocelectomy in Nonobstructive Azoospermic Patients with Varicocele

Background. Infertile men with nonobstructive azoospermia (NOA) associated with varicocele may benefit from varicocele repair with recovered sperms in semen. Currently, there is no clinically applied method to predict the success of seminal sperm recovery in this subset of azoospermic men. Objective. We aimed to evaluate the predictive role of the seminal testis expressed protein (TEX101) in sperm recovery in the semen of NOA men with palpable bilateral varicocele after microsurgical varicocelectomy. Patients and Methods. This prospective cross-sectional cohort study included 40 patients with NOA and bilateral varicocele. Seminal TEX101 levels were measured followed by subinguinal microsurgical varicocele repair. Two seminal analyses were carried out at 3- and 6-month follow-up periods to evaluate seminal sperm recovery. Results. After varicocele repair, sperms were recovered in the semen of 10/40 patients (25%) along the follow-up periods (seven patients after 3 months and additional three patients after 6 months). The preoperative median seminal TEX101 level was significantly higher in NOA men with seminal sperm recovery compared with NOA patients without seminal sperm recovery (13.5 vs. 9.8 ng/ml, p = 0.014 ). Besides, the serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) median levels were significantly higher in NOA men without seminal sperm recovery compared with NOA men with seminal sperm recovery ( p = 0.001 , p = 0.01 ). There were nonsignificant differences comparing the preoperative testicular volume or serum testosterone levels between the two investigated groups ( p = 0.072 , p = 0.272 ). A cutoff value of 9.9 ng/ml was demonstrated to have preoperative TEX101 prediction of seminal sperm recovery (sensitivity of 90% and specificity of 57%). Conclusion. Preoperative seminal TEX101 could be considered as a biomarker for sperm recovery for seminal sperm recovery in NOA cases associated with varicocele after its surgical repair. Further work at this point with larger number of cases should be carried out to verify its potential importance.

Safety and efficacy of acupuncture for varicocele-induced male infertility: a systematic review protocol

INTRODUCTION

Varicocele (VC) is a common clinical disease in andrology. Among a number of ways for VC treatment, surgery is the most common one, but the measurable benefit of surgical repair was slight. A growing exploration of complementary therapies has been conducted in clinical research on acupuncture for VC, but there is no relevant systematic review and meta-analysis to assess the efficacy and safety of acupuncture for VC.

METHODS AND ANALYSIS

All relevant publications published from database inception through August 2022 will be searched in three English-language databases (Embase, CENTRAL, MEDLINE) and four Chinese-language databases (China National Knowledge Infrastructure, China Science and Technology Journal Database, Chinese Biomedical Literature Database and Wanfang Data). Randomised controlled trials in English and Chinese concerned with acupuncture for patients with VC will be included. The input clinical data will be processed by the Review Manager software (RevMan). The literature will be appraised with the Cochrane Collaboration risk of bias tool. The Grading of Recommendations Assessment, Development and Evaluation system (GRADE system) will be used to evaluate the quality of evidence.

ETHICS AND DISSEMINATION

This study is a secondary study based on clinical studies so it does not relate to any individual patient information or infringe the rights of participants. Hence no ethical approval is required. The results will be reported in peer-reviewed journals or disseminated at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42022316005.

Varicoceles in Men With Non-obstructive Azoospermia: The Dilemma to Operate or Not

The knowledge on male reproduction is constantly expanding, especially in treating infertility due to non-obstructive azoospermia (NOA). Varicocele is occasionally diagnosed in a subpopulation of males with NOA. Varicocele repair in NOA-men may contribute to the reappearance of spermatozoa in semen. However, spontaneous pregnancies are observed in only a small percentage of NOA-men post-varicocelectomy. Additionally, it has been reported that the repair of varicocele in NOA-men (before the performance of sperm retrieval techniques) may increase the testicular sperm recovery rate. In addition, it increases the pregnancy rate in intracytoplasmic sperm injection (ICSI) programs in NOA-men without spermatozoa in the semen post-varicocelectomy. In addition, to the improvement in Sertoli cellular secretory function, varicocelectomy may increase the secretory function of Leydig cells, which subsequently results in improved androgen production, raising the probability to negate the need for testosterone replacement therapy in cases of late-onset hypogonadism. On the other hand, the benefit of varicocelectomy in patients with NOA is still debatable. The current review study aims to provide a critical and extensive review of varicocele repair in males with NOA. This study additionally focuses on the impact of varicocele repair on sperm retrieval rates and its influence on the ICSI outcomes for those couples who remain negative for spermatozoa in their semen samples post-varicocelectomy.

Varicocele treatment in non-obstructive azoospermia: a systematic review

Objective: To review the available literature and identify factors associated with successful outcomes after varicocele repair (VR) in the setting of non-obstructive azoospermia (NOA). Methods: The PubMed and EMBASE databases were searched for relevant articles. Primary outcomes were return of spontaneous spermatogenesis, sperm retrieval rates (SRRs), and unassisted and assisted pregnancy rates. Histopathological subtypes, when available, were used for subgroup analysis. Results: A total of 16 articles were finally included. The average sample size was 43 and average duration of follow-up was 10.5 months. The average rate of primary spermatogenesis after VR was 27.3%. The average SRR, across five studies in men with NOA undergoing microscopic testicular sperm extraction status after varicocelectomy, was 48.9% vs 32.1% for the untreated cohort groups, and the average spontaneous pregnancy rate was 5.24%. Histopathology subtype was a significant contributing factor when analysed. Conclusion: Varicocele repair should be considered in men with NOA, as it may allow some patients to avoid assisted reproductive technologies and improves success rates when utilised.

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.

Effect of microsurgical varicocelectomy on semen parameters, serum, and intratesticular testosterone levels

Objective

The goal of this work was to evaluate if men who underwent microsurgical varicocelectomy would have improvement in serum testosterone (T) as well as serum 17-hydroxyprogesterone (17-OHP-An intratesticular T biomarker) in addition to semen parameters after operation.

Materials and Methods

We conducted a prospective analysis of 30 men who underwent microsurgical varicocelectomy from December 2018 to September 2019. We assessed varicocele grade and laterality, serum T, serum 17-OHP, serum follicle- stimulating hormone (FSH), serum LH, and semen parameters in baseline and follow-up. According to the data distribution, we reported the median and interquartile ranges and utilized the Mann-Whitney U, Student's t test and Wilcoxon rank test. Correlation analysis was performed with the Spearman test.

Results

In the baseline, 9 (30%) men had 17-OHP < 55 ng/dL and 21 (70%) men presented with 17-OHP > 55 ng/dL. Also, 19 men had TMSC < 9 million, including 6 men with azoospermia, 1 man with cryptozoospermia, and 11 men with TMSC > 9 million. We found an improvement in most SA parameters of most men, which include concentration (63.3%, 19/30), motility (46.6%, 14/30), and TMSC (60%, 18/30). About seven (36.8%) men had TMSC upgraded to > 9. There was a significant change in volume (2.1 [1.5-2.8] to 2.4 [1.7-3.6] cc, P = .018), concentration (6.8 [0.8-22.5] to 12.5 [1-31] million/cc, P = .047) and TMSC (4.4 [0.3-15.1] to 10.5 [0-41.8] million, P = .012) after surgery. We neither found a change in serum T nor a change in intratesticular T (serum 17-OHP) after varicocelectomy (P > .05). FSH, LH and T were similar both before and after varicocelectomy (P > .05).

Conclusion

Despite improvement in semen parameters following varicocelectomy, we did not see changes in either serum or intratesticular T. This suggests that improvement of semen parameters following varicocele repair could be from factors other than changes in androgen levels within the testis.