Varicocele and male infertility: current concepts and future perspectives

Drainage of varicose veins during subinguinal microscopic varicocelectomy (vein milking): Does it affect pain, cosmetic appearance, and spermiogram?

INTRODUCTION

Varicocele, defined as abnormal convoluted enlargement of the pampiniform plexus veins, is the most common cause of correctable male infertility. This study aimed to investigate the effect of blood drainage in varicose veins on spermiogram parameters, postoperative pain, cosmetic appearance, and patient satisfaction in patients undergoing subinguinal microscopic varicocelectomy.

METHODS

Patients diagnosed with clinical varicocele and admitted to our urology outpatient clinic between January 2020 and January 2024 were evaluated. Those with a venous vessel diameter ≥ 2.5 mm underwent subinguinal microscopic varicocelectomy. In 75 patients, a small incision was made in the thickest varicose vein, and the veins were ligated after venous blood was drained by hand patting. In another 75 patients, vessels were cut and ligated by the classical method without venous blood drainage. Exclusion criteria included patients younger than 18, those with secondary varicocelectomy history, undescended testis, testicular trauma or tumors, and prior infertility treatment. Preoperative and postoperative spermiogram values, pain scores, cosmetic appearance, and patient satisfaction were recorded and compared.

RESULTS

The pain rate was significantly lower (p < 0.05) in the blood-milking varicocelectomy group during postoperative controls (7-10 days) compared to the classical method group. The blood-milking group also showed significantly higher (p < 0.05) sperm count and motility at the 3rd postoperative month. Cosmetic satisfaction was significantly higher (p < 0.05) in the blood-milking group.

CONCLUSIONS

Blood drainage during subinguinal microscopic varicocelectomy significantly reduces postoperative pain and enhances sperm values, cosmetic outcomes, and patient satisfaction. These findings suggest that vein-milking techniques during varicocelectomy can optimize postoperative outcomes.

Comparative Impact of Microsurgical Varicocelectomy Versus Observation on Infertility in Infertile Men With Subclinical Varicocele

PURPOSE

The efficacy of varicocelectomy in treating infertility among men with ultrasonography-detected subclinical varicocele continues to be a topic of clinical uncertainty. This multicentric, prospective, non-randomized study aimed to evaluate the effect of microsurgical ligation of the internal spermatic vein in men with left subclinical varicocele and no other infertility causes.

PATIENTS AND METHODS

The study included 34 infertile men diagnosed with subclinical left varicocele by color Doppler ultrasonography. After a shared decision-making process, the participants self-selected either microsurgical ligation (n = 18) or conservative management (n = 16). Baseline age, duration of infertility, reproductive hormone levels, and semen parameters were comparable across groups. The primary outcomes included changes in sperm concentration, progressive motility, and morphology over a nine-month follow-up period.

RESULTS

After nine months, there were no statistically significant differences between the surgery and observation groups in sperm concentration or progressive motility. After adjusting for baseline values, sperm concentration increased by 3 × 106/mL (95% CI: -6.1 to 12.1), and progressive motility improved by 7.1% (95% CI: -1.3 to 15.5%) post-surgery, although these increases were not significant. However, the surgical group demonstrated a significant 5.6% improvement in sperm morphology (95% CI: 0.1 to 11.2%, p = 0.045) compared to observation.

CONCLUSION

Although this study's small sample size limits its broader generalizability, its findings provide limited evidence that microsurgical ligation may modestly improve sperm morphology in men with subclinical varicocele. Further research with larger, randomized cohorts is warranted to confirm these results and assess potential fertility outcomes.

Involvement of autophagy in germ cells in an experimental model of varicocele in rats before and after varicocelectomy

INTRODUCTION

Autophagy, a catabolic process enabling cellular organelles and proteins' reuse for energy, has been observed in varicocele models, but the effect of surgical treatment on this process remains unknown. This study aims to assess autophagy in varicocele models undergoing surgical correction.

MATERIALS AND METHODS

Twenty-one adolescent male rats were induced with varicocele and divided into three groups: sham, varicocele, and varicocele with varicocelectomy. After 21 days, testicles were examined histologically for spermatogenesis (Jonhsen's score) and immunohistochemically for autophagy markers (LC3A, Beclin-1, Ambra-1, ULK-1, p62). Positive germ cells were quantitatively evaluated, and data were statistically analyzed (p < 0.05).

RESULTS

Histological examination revealed significantly reduced Jonhsen's scores in varicocele compared to sham and varicocelectomy groups (p < 0.05). Expression of autophagy markers (LC3A, Beclin-1, Ambra-1, ULK-1, p62) was significantly higher in varicocele than sham and varicocelectomy groups (p < 0.05), and in varicocelectomy than sham (p < 0.05).

CONCLUSIONS

Varicocele activates autophagy markers, with p62 potentially modulating autophagy despite being considered an inhibitor. While varicocelectomy improves histology, it doesn't fully inhibit autophagy, suggesting ongoing germ cell dysfunction despite treatment. This underscores varicocele's detrimental effects on germ cell functionality.

Mendelian randomization analysis and validation supports MEGF9 and MLLT11 as potential targets for the treatment of varicocele and male infertility

Objective

A growing body of research suggests a link between varicocele and male infertility (MI). However, current evidence is mainly based on retrospective studies, which are prone to interference from confounding factors and cannot establish causal relationships. Mendelian randomization (MR) studies on the causal relationship between varicocele and MI are very limited. Therefore, this study conducted a two-sample MR study to elucidate the causal effect between the two.

Methods

Download the data set GSE216907 from the GEO database, and use R software to screen differential genes in normal and varicocele tissue samples. The drug targets of Bu Shen Huo Xue Prescription (BSHXP) were derived from the Herb database. All genetic datasets were obtained using publicly available summary statistics based on individuals of European ancestry from the IEU GWAS database. MR analysis was performed using MR Egger, weighted median (WM) and inverse variance weighted (IVW) methods to assess the causal relationship between exposure and outcome and to validate the findings by comprehensively evaluating the effects of pleiotropic effects and outliers. The renal vein constriction method was used to establish a pathological model of varicocele infertility. The drug was administered continuously for 60 days and the relevant indicators of the rats were observed.

Results

Obtain two therapeutic targets for varicocele through intersection analysis: MEGF9 and MLLT11, and were verified by molecular docking. MR analysis showed that MEGF9 was positively associated with MI (MR Egger, OR: 1.639, 95% CI: 1.124-2.391, P = 0.024; WM, OR: 1.235, 95% CI: 1.003-1.521, P = 0.047). MEGF9 is also positively associated with MI (IVW, OR: 1.35, 95% CI: 1.069-1.705, P = 0.012). Sensitivity analysis showed no heterogeneity and horizontal pleiotropy. The expression of MEGF9 and MLLT11 increased in the varicocele model group, while the expression decreased after treatment with low, medium, and high doses of BSHXP. In addition, the sperm number, motility, morphology, and fertility of rats in the model group were significantly lower than those in the control group (P<0.05). After BSHXP treatment, all indicators were significantly better than those of the model group (P<0.05).

Conclusion

In conclusion, this study indirectly supports that varicocele causes MI. BSHXP inhibiting MEGF9 and MLLT11 may become a potential therapeutic target for alleviating varicocele and MI.

[Varicocele and male infertility]

BACKGROUND

Varicocele is the most common correctable cause of male infertility. It was the subject of recent Association française d'urologie (AFU) Comité d'andrologie et de médecine sexuelle (CAMS) recommendations. Since then, the literature has provided additional information. This review will comprehensively reassess current indications for the treatment of varicocele, and revisit contemporary issues in the light of current advances.

METHODS

Update of the literature search carried out as part of the CAMS recommendations for the period between 2020 and 2023.

RESULTS

Microsurgical sub-inguinal varicocelectomy remains the surgical treatment of choice for infertile men with clinical varicocele and abnormal sperm parameters. It offers recurrence rates of less than 4%. It significantly improves both natural and in vitro fertilization live birth and pregnancy rates, as well as sperm count, total and progressive motility, morphology and DNA fragmentation rates. All in all, it modifies the MPA strategy in around one in two cases. Varicocele grade and bilaterality are predictive of improved sperm parameters and pregnancy rate. Treatment of subclinical varicocele is not recommended. Complications are rare, notably hydroceles (0.5%), unilateral testicular atrophy due to arterial damage (1/1000), hematomas, delayed healing and postoperative pain. Retrograde embolization is an alternative to surgery.

CONCLUSION

Whenever possible, the urologist should present and discuss treatment options for varicocele with the MPA team and the patient, taking a personalized approach.

Oxidative Stress and Male Infertility: The Protective Role of Antioxidants

Oxidative stress is a significant factor in male infertility, compromising sperm function and overall reproductive health. As male infertility garners increasing attention, effective therapeutic interventions become paramount. This review investigates the therapeutic role of antioxidants in addressing male infertility. A detailed examination was conducted on antioxidants such as vitamin C, E, B12, D, coenzyme Q10, zinc, folic acid, selenium, l-carnitine, l-arginine, inositols, and alpha-lipoic acid. This analysis examines the methodologies, outcomes, and constraints of current clinical studies. Antioxidants show notable potential in counteracting the negative effects of oxidative stress on sperm. Based on the evidence, these antioxidants, individually or synergistically, can enhance sperm health and reproductive outcomes. However, certain limitations in the studies call for careful interpretation. Antioxidants are integral in tackling male infertility attributed to oxidative stress. The current findings underscore their therapeutic value, yet there's a pressing need for deeper, comprehensive research. Future studies should focus on refining dosage guidelines, identifying potential side effects, and discerning the most efficacious antioxidant combinations for male infertility solutions.

The contemporary role of varicocele repair: why operate when in-vitro fertilization results are so good?

PURPOSE OF REVIEW

A male factor is either the primary cause or is contributory in at least half of all couples with infertility. Currently, many male factor problems may be disregarded, as reproductive technology has advanced so much that in-vitro fertilization (IVF)/Intracytoplasmic sperm injection (ICSI) allows the use of even a single sperm to achieve pregnancy.

RECENT FINDINGS

Varicocele is the most commonly diagnosed correctable cause. Microsurgical repair is considered the gold standard for repair. Research has shown that varicocele repair can impact the outcome of reproductive management and upgrade male infertility from adoption or donor sperm only to IVF/ICSI and microTESE, or IVF/ICSI with ejaculated sperm, or from IVF/ICSI to intrauterine insemination (IUI) or often naturally conceived.

SUMMARY

Varicocele diagnosis and repair is an essential part of infertility evaluation. Not only does it potentially impact antiretroviral therapy choices, but it can also increase testosterone levels benefiting long-term male health.

Verbascoside attenuates experimental varicocele-induced damage to testes and sperm levels through up-regulation of the hypothalamus-pituitary-gonadal (HPG) axis

CONTEXT

Verbascoside (VB), which is found in many medicinal plant families, exhibits biological activities in various diseases. However, its effects on varicocele (VCL)-induced damage remain unknown.

OBJECTIVE

To investigate the effects and mechanism of VB on experimental rats with varicocele (VCL)-induced damage.

MATERIALS AND METHODS

Sixty sexually mature male Sprague-Dawley (SD) rats were divided into six groups (n = 10): control, control-sham, VCL-vehicle (normal saline), and VCL + VB groups (50, 100, and 200 mg/kg/day, intraperitoneally). After 4 weeks of VB treatment, all animals were sacrificed, and the body and testicular weight, sperm quality parameters, histopathology, antioxidant status, and hormone levels were tested. The levels of gonadotropin-releasing hormone (GnRH) and gonadotropin-inhibitory hormone in the hypothalamus were detected by western blot.

RESULTS

Compared with the VCL-vehicle group (41.14%), administration of VB significantly increased the sperm viability (59.29, 65.45, 84.93%). VB groups showed higher Johnson's score (3.57 ± 0.15, 4.71 ± 0.26, 7.93 ± 0.37) than VCL-vehicle group (2.72 ± 0.24). Antioxidant status and hormone levels alterations were also observed. Meanwhile, the mean number of apoptotic tubules (8.15 ± 0.96, 6.61 ± 1.05, 2.17 ± 0.08) and apoptotic index showed a marked decrease. Compared with the VCL-vehicle group (0.21 ± 0.09), the VB groups (0.36 ± 0.07, 0.42 ± 0.06, 0.88 ± 0.10) showed considerable increases in GnRH.

DISCUSSION AND CONCLUSIONS

VB has protective effects on reproductive organs and VB may be therapeutically useful in the treatment of varicocele through up-regulation of the HPG axis.

Utility of Antioxidants in the Treatment of Male Infertility: Clinical Guidelines Based on a Systematic Review and Analysis of Evidence

It is widely accepted that oxidative stress plays an important role in the pathophysiology of male infertility and that antioxidants could have a significant role in the treatment of male infertility. The main objectives of this study are: 1) to systematically review the current evidence for the utility of antioxidants in the treatment of male infertility; and 2) propose evidence-based clinical guidelines for the use of antioxidants in the treatment of male infertility. A systematic review of the available clinical evidence was performed, with articles published on Scopus being manually screened. Data extracted included the type of antioxidant used, the clinical conditions under investigation, the evaluation of semen parameters and reproductive outcomes. The adherence to the Cambridge Quality Checklist, Cochrane Risk of Bias for randomized controlled trials (RCTs), CONSORT guidelines and JADAD score were analyzed for each included study. Further, we provided a Strength Weakness Opportunity Threat (SWOT) analysis to analyze the current and future value of antioxidants in male infertility. Of the 1,978 articles identified, 97 articles were included in the study. Of these, 52 (53.6%) were uncontrolled (open label), 12 (12.4%) unblinded RCTs, and 33 (34.0%) blinded RCTs, whereas 44 (45.4%) articles tested individual antioxidants, 31 (32.0%) a combination of several products in variable dosages, and 22 (22.6%) registered antioxidant products. Based on the published evidence, we 1) critically examined the necessity of additional double-blind, randomized, placebo-controlled trials, and 2) proposed updated evidence-based clinical guidelines for antioxidant therapy in male infertility. The current systematic review on antioxidants and male infertility clearly shows that antioxidant supplementation improves semen parameters. In addition, it provides the indications for antioxidant treatment in specific clinical conditions, including varicocele, unexplained and idiopathic male infertility, as well as in cases of altered semen quality.

Proteomic analysis of seminal plasma from bilateral varicocele patients indicates an oxidative state and increased inflammatory response

Seminal plasma is a rich source of proteins and serves as an ideal sample for proteomic analysis of male infertility. In varicocele-associated infertility, the contributory role of seminal plasma proteins specific to unilateral and bilateral varicocele is not clear. Furthermore, there is a lack of specific protein biomarker to differentiate bilateral from unilateral varicocele. The main objective is to identify the differentially regulated molecular and cellular pathways in bilateral varicocele. Furthermore, we intend to identify seminal plasma biomarkers to differentiate bilateral and unilateral varicocele patients in comparison with fertile healthy men. Global proteomic analysis of seminal plasma proteins has identified the functionality of differentially expressed proteins (DEPs) in varicocele patients. Bioinformatic analysis has revealed response to reactive oxygen species and oxidative stress, and tissue homeostasis as top process pathways that are affected in bilateral varicocele patients compared to fertile healthy men. In comparison with unilateral varicocele patients, inflammatory response pathways were dysregulated, especially interleukin 6 (IL-6) signaling and Janus kinase-signal transducer and activator of transcription (Jak-STAT) pathways, in bilateral varicocele patients, owing to the involvement of underexpressed DEPs. Key DEPs associated with oxidative stress (peroxiredoxin 2; PRDX2), DNA fragmentation (fatty acid synthase; FASN), and inflammatory response (fibronectin 1; FN1) validated by western blot analysis revealed differential expression of these proteins in unilateral and bilateral varicocele groups. Altered expression of DEPs and its association with key processes show that the seminal plasma homeostasis is compromised in bilateral varicocele patients. Furthermore, we propose PRDX2, FASN, and FN1 as potential noninvasive seminal plasma markers for the differentiation of unilateral and bilateral varicocele patients.

Endoplasmic Reticulum Stress (ER Stress) and Unfolded Protein Response (UPR) Occur in a Rat Varicocele Testis Model

Using a surgically induced varicocele rat model, we show here strong evidence that the misfolded/unfolded protein response that is part of the stress response of the endoplasmic reticulum (ER) is activated in the varicocele testis (VCL), leading to the induction of apoptosis. To support this hypothesis, it is observed that the spliced variant of the X-box protein 1 (XBP1s), resulting from the activation of the inositol-requiring enzyme 1 (IRE1) membrane sensor, is significantly more represented in VCL testicular extracts. The activation of the IRE1/XBP1s pathway is also supported by the observation that the VCL testes show an increase phosphorylation of the c-Jun-kinase (JNK) known to be one intermediate of this pathway and an increased level of caspase-3, the terminal apoptotic effector, partly explaining the apoptotic status of the VCL testis.

Oxidative stress and male infertility: current knowledge of pathophysiology and role of antioxidant therapy in disease management

Infertility is a global health problem involving about 15% of couples. Approximately half of the infertility cases are related to male factors. The oxidative stress, which refers to an imbalance in levels of reactive oxygen species (ROS) and antioxidants, is one of the main causes of infertility in men. A small amount of ROS is necessary for the physiological function of sperm including the capacitation, hyperactivation and acrosomal reaction. However, high levels of ROS can cause infertility through not only by lipid peroxidation or DNA damage but inactivation of enzymes and oxidation of proteins in spermatozoa. Oxidative stress (OS) is mainly caused by factors associated with lifestyle. Besides, immature spermatozoa, inflammatory factors, genetic mutations and altering levels of sex hormones are other main source of ROS. Since OS occurs due to the lack of antioxidants and its side effects in semen, lifestyle changes and antioxidant regimens can be helpful therapeutic approaches to overcome this problem. The present study aimed to describe physiological ROS production, roles of genetic and epigenetic factors on the OS and male infertility with various mechanisms such as lipid peroxidation, DNA damage, and disorder of male hormone profile, inflammation, and varicocele. Finally, the roles of oral antioxidants and herbs were explained in coping with OS in male infertility.

Oxidative stress and male infertility: current knowledge of pathophysiology and role of antioxidant therapy in disease management

Infertility is a global health problem involving about 15% of couples. Approximately half of the infertility cases are related to male factors. The oxidative stress, which refers to an imbalance in levels of reactive oxygen species (ROS) and antioxidants, is one of the main causes of infertility in men. A small amount of ROS is necessary for the physiological function of sperm including the capacitation, hyperactivation and acrosomal reaction. However, high levels of ROS can cause infertility through not only by lipid peroxidation or DNA damage but inactivation of enzymes and oxidation of proteins in spermatozoa. Oxidative stress (OS) is mainly caused by factors associated with lifestyle. Besides, immature spermatozoa, inflammatory factors, genetic mutations and altering levels of sex hormones are other main source of ROS. Since OS occurs due to the lack of antioxidants and its side effects in semen, lifestyle changes and antioxidant regimens can be helpful therapeutic approaches to overcome this problem. The present study aimed to describe physiological ROS production, roles of genetic and epigenetic factors on the OS and male infertility with various mechanisms such as lipid peroxidation, DNA damage, and disorder of male hormone profile, inflammation, and varicocele. Finally, the roles of oral antioxidants and herbs were explained in coping with OS in male infertility.

Regulatory Functions of MicroRNAs in Male Reproductive Health: A New Approach to Understanding Male Infertility

MicroRNAs (miRNAs) are a novel class of small noncoding RNAs (ncRNAs) that play critical roles in regulation of gene expression, especially at posttranscriptional level. Over the past decade, the degree to which miRNAs are involved in male infertility has become clear. They are expressed in a cell- or phase-specific manner during spermatogenesis and play crucial role in male reproductive health. Therefore, dysregulation of miRNAs in testicular cells can be considered as a molecular basis for reproductive failure and male infertility. The abnormal expression pattern of miRNAs can be transmitted to the offspring via assisted reproductive techniques (ART) and results in the birth of children with a higher risk of infertility, congenital abnormalities, and morbidity. This review expounds on the miRNAs reported to play essential roles in somatic cells development, germ cells differentiation, steroidogenesis, normal spermatogenesis, sperm maturation, and male infertility, as well as emphasizes their importance as minimally invasive biomarkers of male infertility.

Varicocele and male infertility: current concepts and future perspectives

This Special Issue of Asian Journal of Andrology is fully dedicated to the thematic area of Varicocele, which has been one of the most controversial issues in the field of Urology, Andrology, and Reproductive Medicine. Recognized as a clinical entity for over a century, varicocele from Latin: varix (dilated vein) and from Greek: kele (tumor) still elicits heated debate among scientists and clinicians on an arguable negative effect on male fertility and gonadal function and has fueled thousands of scholarly articles since its first report in the 18^th century.

Afterword to varicocele and male infertility: current concepts and future perspectives

We summarize and comment on the topics discussed by the contributors to this Special Issue of Asian Journal of Andrology. The scope of varicocele covers a wide spectrum, including proteomics and metabolomics, hormonal control, interventional therapy, and assisted reproductive technology (ART). The selection of topics demonstrates the exciting breadth of this thematic area and the opportunity research holds for both increasing the understanding and improving the reproductive health of males with varicocele.

Novel concepts in male factor infertility: clinical and laboratory perspectives

In recent years, the management of male factor infertility has undergone important changes with the introduction of novel concepts, advanced testing, and therapeutic interventions. This review highlights some of these changes and discusses their impact to routine clinical practice. First, we discuss the recent changes in the World Health Organization (WHO) laboratory methods and reference values for the examination of human semen. Second, we examine the role of sperm chromatin integrity tests in light of increasing evidence of the detrimental effect of sperm DNA fragmentation on reproductive outcomes. Third, we summarize the main findings of varicocele-related infertility and the outcomes of microsurgical varicocele repair to different case scenarios. Lastly, we critically discuss the current management of men with nonobstructive azoospermia seeking fertility and the new opportunities that emerged to help these men achieve biological fatherhood.