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

Testicular arterial blood flow volume in predicting semen improvement following microscopic subinguinal varicocelectomy

Background

Varicocele is a significant but treatable contributor to male infertility. The efficacy of varicocelectomy in improving sperm quality is not consistent, with only 60-80% of patients experiencing improved semen quality. This prospective cohort study aimed to evaluate the effect of microscopic subinguinal varicocelectomy (MSV) on testicular arterial blood flow volume (TABFV) and to determine the value of preoperative TABFV in predicting the outcome of MSV.

Methods

Patients with varicocele who underwent MSV at the same clinical center between July 2020 and April 2023 were enrolled. All patients underwent ultrasound assessment and at least one semen analysis before and after MSV. Both univariate and multivariate logistic regression analyses were performed to assess the association between pre-MSV variables and semen improvement after MSV. Subsequently, a diagnostic model was developed.

Results

This study enrolled 96 patients with varicocele, including 31 who showed semen improvement after MSV and 65 who did not. The postoperative semen-improved group demonstrated a significant increase in TABFV of the right testis (TABFV-R) and left testis (TABFV-L) (P<0.001). Notably, the postoperative TABFV-L was more than twice the preoperative TABFV-L. Preoperative TABFV-R and a combination of subclinical right-sided varicocele were found to be associated with semen improvement after MSV, and a diagnostic model was developed using these two variables. The diagnostic model exhibited satisfactory performance, with an area under the curve (AUC) of 0.824 [95% confidence interval (CI): 0.735-0.913], which was further validated internally yielding an AUC of 0.824 (95% CI: 0.726-0.900). Additionally, calibration analysis confirmed that the diagnostic model was well calibrated, and the Hosmer-Lemeshow test resulted in a P value of 0.794. The decision curve demonstrated that using this proposed nomogram would yield a net benefit if the threshold probability for semen improvement after MSV exceeded 10%.

Conclusions

TABFV-L demonstrated potential utility in clinical practice for assessing outcomes of MSV, and the diagnostic model incorporating TABFV-R and a combination of right-side varicocele performed well in predicting improvements in semen parameters following MSV.

The Andrological Landscape in the Twenty-First Century: Making Sense of the Advances in Male Infertility Management for the Busy Clinicians

Male infertility represents a significant global problem due to its essential health, social, and economic implications. It is unsurprising that scientific research is very active in this area and that advances in the diagnostic and therapeutic fields are notable. This review presents the main diagnostic advances in male infertility, starting from the changes made in the latest WHO Manual of semen analysis and discussing the more molecular aspects inherent to "omics". Furthermore, the usefulness of artificial intelligence in male infertility diagnostics and the latest advances in varicocele diagnosis will be discussed. In particular, the diagnostic path of male infertility is increasingly moving towards a personalized approach to the search for the specific biomarkers of infertility and the prediction of treatment response. The treatment of male infertility remains empirical in many regards, but despite that, advances have been made to help formulate evidence-based recommendations. Varicocele, the most common correctable cause of male infertility, has been explored for expanded indications for repair. The following expanded indications were discussed: elevated sperm DNA fragmentation, hypogonadism, orchalgia, and the role of varicocele repair in non-obstructive azoospermia. Moving forward with the available data, we discussed the stepwise approach to surgical sperm retrieval techniques and the current measures that have been investigated for optimizing such patients before testicular sperm extraction. Finally, the key points and expert recommendations regarding the best practice for diagnosing and treating men with infertility were summarized to conclude this review.

Predictive parameters of the efficacy of varicocele repair: a review

ABSTRACT

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.

[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.

Mailuoshutong pill for varicocele-associated male infertility—Phytochemical characterisation and multitarget mechanism

Background: Varicocele (VC) is a relatively common and treatable cause of male infertility. Mailuoshutong pill (MLST), a traditional Chinese patent medicine, is widely used for treating varicose vein disease, but the underlying mechanism of MLST on varicocele-associated male infertility is unclear.

Objective: To reveal the phytochemical characterisation and multitarget mechanism of MLST on varicocele-associated male infertility.

Methods: The components in MLST were determined using UHPLC-MS/MS. Through network analysis, we constructed the “Drug-Components-Targets-Disease” network and predicted the potential biological functions and signaling pathways of MLST. Finally, the therapeutic effects and potential mechanisms of MLST were discovered by pharmacological experiments.

Results: By network analysis, the “Drug-Components-Targets-Disease” network was constructed, 62 components such as apigenin, limonin, kaempferol, and obacunoic acid may be the main active components of MLST for varicocele-associated male infertility, 28 targets such as VEGFA, PIK3CA, AKT1, and MTOR are considered as hub targets, signaling pathways such as HIF-1, Estrogen, PI3K/Akt, and mTOR may be key pathways for MLST against varicocele-associated male infertility. Through pharmacological experiments, we found that MLST ameliorated VC-induced testicular atrophy. Further histomorphology showed that MLST reduced VC-induced damage to testicular spermatogonia and seminiferous tubule, while MLST reduced ROS and MDA levels and increased antioxidant enzymes (GSH, GSH-Px, SOD, and CAT) levels. TUNEL staining and immunofluorescence showed that MLST reduced VC-induced apoptosis in testicular tissue, decreased BAX, and increased BCL2. Western blot results showed that MLST decreased the phosphorylation of PI3K, AKT, and mTOR proteins, and decreased the expression of HIF1α.

Conclusion: The phytochemical characterisation and multitarget mechanism of MLST on varicocele-associated male infertility were discovered using network analysis and pharmacological experiments. We verified that MLST can inhibit the activation of the PI3K/Akt/mTOR signaling pathway, reduce the expression of HIF1α, and further attenuate VC-induced oxidative stress and apoptosis in the testis. These findings provide evidence for the therapeutic role of MLST in varicocele-associated male infertility.