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

Predictive parameters of the efficacy of varicocele repair: a review

ABSTARCT

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.

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.

Nomogram for Predicting Semen Parameters Improvement after Microscopic Varicocelectomy in Infertile Men with Abnormal Semen Parameters

Objectives: Information on the prediction of improved semen parameters following varicocelectomy is scarce and mostly contradictory. Therefore, we developed and validated a nomogram to predict whether abnormal semen parameters in infertile men could improve following microscopic varicocelectomy (MSV). Methods: From January 2018 to December 2021, 460 consecutive patients who underwent MSV were included. Of them, 336 patients as a development cohort at the Xiang Hua institution. As a validation cohort, Hu Nan Center (124 patients) was used. Clinicopathologic patient information was recorded. The likelihood ratio test using Akaike’s information criteria was employed as the stopping rule, and multivariate logistic regression was utilized to create a prediction model with regression coefficients. The effectiveness of this prediction model was evaluated based on its ability of discrimination, calibration, and clinical utility. Results: The initial total progressively motile sperm count (TPMSC) and vein diameter were predictors of this model. The model demonstrated strong discrimination for the validation cohort, with an area under the receiver operating characteristic (AUROC) of 0.925 (p < 0.001), and strong calibration (unreliability test, p = 0.522). The decision curve study proved the model’s clinical applicability. Conclusion: According to our research, the improvement of semen parameters in infertile men following MSV was significantly predicted by greater vein diameter and higher initial TPMSC. This nomogram aids in individualized decision-making on the varicocele preoperative treatment plan and may help to enhance the therapeutic result.

Nomogram for predicting spontaneous pregnancy after microscopic varicocelectomy in infertile men with normal hormone

Introduction

The current challenge for the treatment of varicocele is identifying patients who could benefit the most from surgery. We aimed to develop and validate a nomogram for predicting spontaneous pregnancy following microscopic varicocelectomy in infertile men, based on a large cohort.

Methods

Two hundred eighty-two consecutive patients who underwent microscopic varicocelectomy from January 2018 to December 2020 were enrolled as participants in the study. Xiang Hua center (206 patients) as a development cohort. Hu Nan center (76 patients) as a validation cohort. Patient clinicopathologic data were recorded. Multivariate logistic regression was used to build a predictive model with regression coefficients. Then, backward stepwise selection was applied, and the likelihood ratio test with Akaike’s information criterion was used as the stopping rule. The performance of this predictive model was assessed for discrimination, calibration, and clinical usefulness.

Results

Predictors of this model included the age of female partners, diameter of veins, initial and increased total progressively motile sperm count. The model demonstrated good discrimination with an AUROC of 0.925 (p < 0.001) and calibration (Unreliability test, p = 0.522) in the validation cohort. Furthermore, the model was clinically useful, according to decision curve analysis.

Conclusions

Our findings indicated that younger female partners, larger diameter of veins, higher initial and increased total progressively motile sperm count were significant predictors of spontaneous pregnancy in infertile men, post microscopic varicocelectomy. This nomogram may assist in individual decision-making on the treatment strategy of varicocele preoperatively and improve the treatment outcome.

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.

Smoking and obesity negatively affect the favourable outcome of varicocelectomy in sub-fertile men

We assessed the effect of smoking and/or obesity on semen parameters and testosterone/oestradiol (T/E) ratio among sub-fertile men treated with sub-inguinal varicocelectomy. In this prospective, controlled, clinical study, 80 sub-fertile men with clinical varicocele who were subjected to sub-inguinal varicocelectomy were assigned into four equal groups (n = 20/each), group A: obese and smokers, group B: obese and nonsmokers, group C: smokers and nonobese and group D: nonsmokers and nonobese. Semen parameters, serum testosterone, oestradiol, follicle-stimulating hormone, luteinising hormone, prolactin and calculation of T/E ratio were assessed at baseline and 6 months post-varicocelectomy. The mean age ± SD of the study population was 26.1 ± 4.55. No statistical difference was detected among the study groups regarding age, residence, education, marital status and occupation (p > 0.05 for each). Post-operatively, significant improvements in semen parameters were detected in all groups. There was a significant difference between groups A and B versus C and D (obese versus nonobese groups) and between groups A and C versus B and D (smokers versus nonsmokers; p < 0.05 for each) regarding semen parameters, testosterone level and T/E ratio. Smoking and/or obesity negatively affect(s) the favourable outcome of varicocelectomy, specifically improvement of semen parameters and hormonal pattern in sub-fertile men with varicocele.

COMBINED TREATMENT OF PATHOSOSPERMIA WITH ADJUVANT THERAPY WITH SPEROTON COM- PLEX IN PATIENTS WITH VARICOCELE

OBJECTIVE To evaluate the effectiveness of combined treatment of pathozoospermia in patients with varicocele by performing micro- surgical phlebectomy of varicose veins of the spermatic cord in combination with adjuvant therapy with the Speroton complex MATERIAL AND METHODS Twenty microsurgical phlebectomies of varicose veins of the spermatic cord were performed in patients with pathozoo- spermia (oligoasthenospermia) against the background of varicocele with the appointment of the Speroton complex in the postoperative period for 3 months with an assessment of spermogram parameters before and after the operation in comparison with a group of 20 men with pathozocelemia without the use of adjuvant therapy. The study of morphological and functional parameters of spermogram of men of reproductive age (18-49 years) without signs of immune infertility (MAR-test IgG <10%) before and after the start of treatment was carried out. The average age of men was 33 ± 2.3 years (M ± m). RESULTS All patients with infertility in combination with varicocele had oligoasthenozoospermia before treatment. Three months after the start of treatment in the study groups, there was a statistically significant improvement in sperm counts due to an increase in the concentration of spermatozoa in 1 ml of ejaculate, an increase in the number of progressively mobile forms and total motility of spermatozoa by 50-68%, an increase in the number of live sperm by 19-20% and a decrease in the num- ber of dead forms of spermatozoa by 30-35%. A statistically significant decrease in the DNA fragmentation index by 34-52% (p <0.05) was found in all study groups. It was found that combination therapy, including microsurgical phlebectomy of the spermatic cord veins using the Speroton complex for 3 months, statistically significantly led to an increase in the concentration of spermatozoa in 1 ml of ejaculate (38.6 [38.2; 69.4]), an increase in progressively mobile forms (49.2 [26.7; 47.2]%) and general motility (72.2 [35.3; 64.7]%) of spermatozoa and viable forms (67.8 [39.3; 81.7] %), a decrease in the DNA fragmenta- tion index compared with the spermogram indicators of patients who underwent only microsurgical phlebectomy (p <0.05 for all study indicators). In the group of patients after combined treatment with the inclusion of adjuvant therapy of the Speroton complex, there was a statistically significant decrease in the sperm DNA fragmentation index to almost normal values (12.1 ± 1.1%) compared with the group of patients who underwent only surgery (17.2 ± 0.8%) (p = 0.01). Combined treatment (micro- surgical phlebectomy of the veins of the spermatic cord in combination with adjuvant therapy Speroton) of pathozoospermia in men of reproductive age with infertility on the background of varicocele can significantly improve the morphofunctional parameters of spermogram after 3 months from the start of treatment compared to men who underwent only surgical correction of varicocele.

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.

Evaluation of the role of reflux pattern in Color Doppler Ultrasound on spermogram improvement after varicocelectomy

PURPOSE

Many attempts are being made to find an association between varicocele characteristics and sperm parameters. In this study, we investigated the association between a newly introduced varicocele reflux grading pattern and sperm parameters, as well as its effect on spermogram improvement after varicocelectomy.

METHODS

In a prospective study, 73 patients with a clinical single-sided varicocele who underwent corrective varicocelectomy were included. Reflux pattern was determined on Color Doppler Ultrasound (CDUS) and categorized into four grades: grade 1 (retrograde), grade 2 (augmentation), grade 3 (enhancement), and grade 4 (stasis). The association of pre- and postoperative spermogram with the patients' reflux pattern was evaluated.

RESULTS

A significant positive association was found between the venous diameter and reflux pattern. Higher grades of the reflux pattern were associated with the more severe hemodynamic pattern of the reflux (shunt type). A significant association was found between the reflux pattern and preoperative semen characteristics, and this association was more prominent in constant venous diameter. In this respect, the enhancing reflux type was associated with the most impaired preoperative sperm count, motility, and morphology. The enhancing type also revealed the most improvement in spermogram after varicocelectomy.

CONCLUSION

Patients with a higher reflex grade, particularly enhancing pattern, will most benefit from the surgical correction of varicocele. These findings suggest reflux pattern as a promising prognostic factor for a favorable outcome after varicocelectomy.