Does Varicocele Repair Improve Conventional Semen Parameters? A Meta-Analytic Study of Before-After Data

PURPOSE

The purpose of this meta-analysis is to study the impact of varicocele repair in the largest cohort of infertile males with clinical varicocele by including all available studies, with no language restrictions, comparing intra-person conventional semen parameters before and after the repair of varicoceles.

MATERIALS AND METHODS

The meta-analysis was performed according to PRISMA-P and MOOSE guidelines. A systematic search was performed in Scopus, PubMed, Cochrane, and Embase databases. Eligible studies were selected according to the PICOS model (Population: infertile male patients with clinical varicocele; Intervention: varicocele repair; Comparison: intra-person before-after varicocele repair; Outcome: conventional semen parameters; Study type: randomized controlled trials [RCTs], observational and case-control studies).

RESULTS

Out of 1,632 screened abstracts, 351 articles (23 RCTs, 292 observational, and 36 case-control studies) were included in the quantitative analysis. The before-and-after analysis showed significant improvements in all semen parameters after varicocele repair (except sperm vitality); semen volume: standardized mean difference (SMD) 0.203, 95% CI: 0.129-0.278; p<0.001; I²=83.62%, Egger's p=0.3329; sperm concentration: SMD 1.590, 95% CI: 1.474-1.706; p<0.001; I²=97.86%, Egger's p<0.0001; total sperm count: SMD 1.824, 95% CI: 1.526-2.121; p<0.001; I²=97.88%, Egger's p=0.0063; total motile sperm count: SMD 1.643, 95% CI: 1.318-1.968; p<0.001; I²=98.65%, Egger's p=0.0003; progressive sperm motility: SMD 1.845, 95% CI: 1.537%-2.153%; p<0.001; I²=98.97%, Egger's p<0.0001; total sperm motility: SMD 1.613, 95% CI 1.467%-1.759%; p<0.001; l2=97.98%, Egger's p<0.001; sperm morphology: SMD 1.066, 95% CI 0.992%-1.211%; p<0.001; I²=97.87%, Egger's p=0.1864.

CONCLUSIONS

The current meta-analysis is the largest to date using paired analysis on varicocele patients. In the current meta-analysis, almost all conventional semen parameters improved significantly following varicocele repair in infertile patients with clinical varicocele.

CIRSE Standards of Practice on Varicocele Embolisation

BACKGROUND

Percutaneous embolisation is an effective, minimally invasive means of treating a variety of benign and malignant lesions and has been successfully used to treat varicoceles since the late 1970s, with refined and expanded techniques and tools currently offering excellent outcomes for varicocele embolisation.

PURPOSE

This document will presume that the indication for treatment is clear and approved by the multidisciplinary team (MDT) and will define the standards required for the performance of each modality, as well as their advantages and limitations. CIRSE Standards of Practice documents are not intended to impose a standard of clinical patient care, but recommend a reasonable approach to, and best practices for, the performance of percutaneous varicocele embolisation.

METHODS

The writing group was established by the CIRSE Standards of Practice Committee and consisted of five clinicians with internationally recognised expertise in embolisation of male varicoceles. The writing group reviewed the existing literature on varicocele embolisation, performing a pragmatic evidence search using PubMed to search for publications in English and relating to human subjects published from 2006 to 2021. The final recommendations were formulated through consensus.

CONCLUSION

Embolisation has an established role in the successful management of male varicoceles. This Standards of Practice document provides up-to-date recommendations for the safe performance of varicocele embolisation.

Liquid and Solid Embolic Agents in Gonadal Veins

Male varicocele and pelvic congestion syndrome (PCS) are common pathologies with high predominance in young patients, having a high impact on the quality of life and infertility. Lately, the use of different endovascular embolization techniques, with various embolizing agents, shows good technical results and clinical outcomes. With the aim of presenting the “state of the art” of endovascular techniques for the treatment of male varicocele and PCS, and to discuss the performance of the different embolic agents proposed, we conducted an extensive analysis of the relevant literature and we reported and discussed the results of original studies and previous meta-analyses, providing an updated guide on this topic to clinicians and interventional radiologists. We have also underlined the technical aspects for the benefit of those who approach this type of interventional treatment. Our review suggests promising results in both the endovascular embolic treatment of male varicocele and PCS; for varicocele, a success rate of between 70% and 100% and a recurrence rate of up to 16% is reported, while for PCS it has been found that technical success is achieved in almost all cases of endovascular treatment, with a highly variable recurrence rate based on reports. Complications are overall rather rare and are represented by periprocedural pain, migration of embolic media and vascular perforations: severe adverse events have been reported very rarely.

Embolization of left spermatic vein in non-obstructive azoospermic men with varicocele: role of FSH to predict the appearance of ejaculated spermatozoa after treatment

PURPOSE

Varicocele repair in non-obstructive azoospermia (NOA) was occasionally associated to ejaculated spermatozoa independently from clinical and laboratory measures. We performed a prospective study in infertile men affected by NOA and left side varicocele to find whether or not the appearance of ejaculated spermatozoa after varicocele repair is predicted by baseline measures.

METHODS

Patients with NOA and grade II, or grade III left side varicocele were submitted to hormone analysis and to scrotal color Doppler ultrasound (CDU). Azoospermia was confirmed in 23 patients aged 25-47 years who were than submitted to varicocele repair through a retrograde internal spermatic vein embolization. Patients were re-evaluated after 6 months.

RESULTS

Six months after varicocele repair 12 patients (52.2 %) were still azoospermic (Group 1) while 11 patients (47.8 %) reported ejaculated spermatozoa (Group 2) [sperm count: 1.3 × 10(6)/mL; 0.5 × 10(6)/mL-1.6 × 10(6)/mL (median 25th-75th centiles)]. Serum baseline FSH was lower in Group 2 compared to Group 1 (p = 0.012), while no differences between groups were revealed for all other clinical and laboratory parameters. ROC analysis indicated that baseline FSH level predicted the appearance of ejaculated spermatozoa after treatment [AUC = 0.811; 95 % Confidence Interval (CI) 0.6-0.9; p = 0.0029]. A cut-off level of FSH <10.06 mIU/mL identified 82.0 % of cases with ejaculated spermatozoa with a specificity of 81.8 % and a sensitivity of 83.3 %.

CONCLUSION

Selected patients with NOA may show ejaculated spermatozoa after a non-invasive repair of a left side varicocele, therefore avoiding testicular sperm extraction. Baseline serum FSH was a valuable predictor for ejaculated spermatozoa after treatment.

Sclerosis and varicocele embolization with N-butyl cyanoacrylate: experience in 41 patients

BACKGROUND

Embolization is an established treatment for varicocele. Coils are most frequently used in the procedure. Liquid embolic and sclerosing agents seem to have a number of advantages over coils.

PURPOSE

To report our experience and explain the technique of using N-2-butyl-cyanoacrylate (N2BCA) in varicocele treatment.

MATERIAL AND METHODS

From January 2010 to July 2011, 42 gonadal veins in 41 consecutive patients (age range, 11-41 years; mean, 18 years) with a diagnosis of varicocele were treated with N2BCA as an embolic agent. The clinical diagnosis was confirmed by Doppler ultrasound in all patients. Institutional review board approval was obtained, and all the patients signed informed consent for this retrospective review. In all cases, a 4-F hydrophilic catheter was used to catheterize the distal portion of the gonadal vein through which N2BCA, emulsified with lipiodol, was injected.

RESULTS

The technical success was 100%. No complications or non-targeted embolizations were reported. Seven patients reported moderate post-embolization pain that required oral analgesic treatment for 7-10 days. After 12-month follow-up, all patients exhibited varicocele resolution in the Doppler ultrasound examination as well as relief of all previous symptoms. We have no fertility-related data for patients treated for this condition.

CONCLUSION

N2BCA as an embolic agent is a therapeutic alternative for the endovascular treatment of varicocele. This technique is uncomplicated, inexpensive, efficient, and safe.

A Proposed Anatomic Typing of the Right Internal Spermatic Vein: Importance for Percutaneous Sclerotherapy of Varicocele

PURPOSE

To classify the anatomic types of the right internal spermatic vein (ISV).

METHODS

We evaluated venograms obtained in 150 consecutive patients with idiopathic varicocele referred for transfemoral sclerotherapy.

RESULTS

Six anatomic types of the right internal spermatic vein (ISV) were recognized. These were classified by the location of their orifices and the tributary venous patterns. In roughly half the patients (53%), the ISV appeared as a simple vein with no remarkable retroperitoneal interconnections. In the remainder, complex retroperitoneal anastomoses were encountered.

CONCLUSION

By understanding these anatomic variations, the angiographer can approach treatment of right-sided varicocele with foreknowledge of the nature of these types and the presence of valves and collaterals.

Four Years' Follow-up Results of Three Different Percutaneous Treatments for Male Varicocele

Objective:

To evaluate the efficacy of three different interventional radiological procedures for the treatment of venous reflux in symptomatic male varicocele.

Design:

Prospective study with a 48-month colour duplex ultrasound (CD) follow-up.

Setting:

Department of Radiology, Tor Vergata University of Rome.

Patients:

From January 1991 to December 1993, 45 symptomatic patients with third- to fourth-degree varicocele, according to Sarteschi's CD classification, were randomly divided into three equal groups (15 patients each).

Interventions:

The first group received sclerotherapy (Athoxysclerol), the second underwent embolisation (Gianturco coils), while the third group received combined sclero–embolisation therapy (Athoxysclerol and Gianturco coils).

Main outcomes measures:

The frequency of recurrence for each procedure.

Results:

Two recurrences (13%) after 1 and 2 years occurred in patients who underwent sclerotherapy. In the embolisation group, two patients showed residual varices (13%). Neither recurrence nor residue was seen in the third group, who received combined therapy.

Conclusions:

Sclerotherapy provides good immediate results but drug dilution may cause a relapse shortly after treatment. Embolisation has a lower immediate success but better long-term success. Combined treatment provides the highest long-term success rate.

Testicular size following embolization therapy for paediatric left varicocele

Optimal management of varicocele testis in children and adolescents is controversial, but testicular hypotrophy has been suggested as an indication for treatment in adolescents. This report concerns the diagnosis and management of left varicocele in 30 patients aged 6-15 years and the influence of treatment on testicular size. The left testicle was significantly smaller than the right in 14 patients at enrollment in the study. All patients were treated in local anaesthesia with percutaneous transfemoral spermatic venography and embolization of that vein with spring coil, followed by 24-hour observation. There were no major complications. At follow-up 9 to 12 months after the treatment, the size of the left testis had increased in 12 patients. Spring-coil embolization of the spermatic vein proved to be a safe and effective technique for treatment of varicocele.

Surgical ligation vs. angiographic embolization of the vena spermatica: a prospective randomized study for the treatment of varicocele-related infertility

Varicoceles as a common cause of male infertility are treated either by surgical ligation or, more recently, by angiographic occlusion of the spermatic vein. In the present prospective randomized study 38 patients were treated by surgical ligation and 33 by angiographic embolization. During the 12-month follow-up period a significant increase in sperm number (at 3 and 12 months) and sperm motility (at 12 months) occurred in both groups while sperm morphology remained unaffected. Altogether, 22 pregnancies (31%) were reported within the year following treatment, of which 11/38 (29%) occurred in the ligation group and 11/33 (33%) in the embolization group. Thus both treatment modalities appear equivalent, whereby embolization has the advantage that it can be performed on an outpatient basis.