Predictors of improvement in semen parameters after varicocelectomy for male subfertility: A prospective study

Surgical efficacy and predictors of outcome in varicocelectomy: a meta-analysis of multivariable studies

BACKGROUND

Varicocele is a common cause of male infertility. Varicocelectomy can effectively improve semen quality, but it does not improve semen quality in all patients.

METHODS

Prior to conducting this meta-analysis, we registered the protocol in PROSPERO (CRD42024574608). Our meta-analysis by searching databases such as Web of Science, Embase, PubMed, and Cochrane Library. Only studies utilizing multivariable logistic regression were included. Odds ratios (OR) with 95% confidence intervals (CI) were calculated to assess the effect size.

RESULTS

The analysis comprised 11 studies with 1,498 patients and encompassed 14 outcomes. The overall efficacy rate of varicocelectomy was 62.8% (95% CI 55.6-69.9%). Compared to other surgical methods and approaches, microsurgical varicocelectomy and subinguinal varicocelectomy demonstrated higher surgical efficacy rates. Higher preoperative sperm concentration (OR = 1.04, 95% CI 1.01-1.06) and total motile sperm count (OR = 3.00, 95% CI 1.04-8.67) were predictive of better post-varicocelectomy outcomes. Furthermore, a positive correlation existed between wider spermatic vein diameter and improved efficacy post-varicocelectomy (OR = 2.41, 95% CI 1.36-4.26).

CONCLUSION

Microsurgical subinguinal varicocelectomy achieves higher surgical efficacy rates. Varicocele patients with better preoperative sperm concentration, total motile sperm count, and wider spermatic vein diameter are more likely to benefit from varicocelectomy. This provides andrologists with a reference basis for advising varicocele patients on the surgical efficacy and potential benefits post-varicocelectomy.

Assessing the outcomes of subinguinal microsurgical varicocelectomy: pulling technique compared to the conventional method

INTRODUCTION

The positive effect of varicocelectomy on sperm parameters (sperm morphology, concentration, motility) and fertility and pregnancy rates has been proven. Although various techniques have been defined for varicocele treatment, varicocelectomy with the pulling technique was first defined in 2017. The aim of this retrospective study is to compare the effectiveness and reliability of subinguinal microsurgical varicocelectomy with the "pulling" technique and conventional subinguinal varicocelectomy.

METHODS

A total of 841 patients who underwent subinguinal microsurgical varicocelectomy using the "pulling" or conventional technique between January 2015 and January 2024 were examined retrospectively. Patients with missing and/or inaccessible data, who were using empirical treatments, were excluded from the study. Demographic data, laboratory and imaging results, and peroperative and postoperative 3rd and 6th month semen analysis results of the remaining 231 patients were evaluated.

RESULTS

The mean age of 231 patients who underwent varicocelectomy was 31.1 ± 5.5 years. 202 of the patients (87.4%) were primary infertile. Conventional technique was applied to 124 (53.7%) of the 231 patients, while pulling technique was applied to 107 (46.3%) patients. No significant difference was found between the demographic and clinical data of the patients. The median number of ligated pampiniform plexus veins in the patient group who underwent pulling technique was statistically significantly less than that in the patient group that underwent the conventional method (4 vs 5, p = 0.03). In all patients who underwent varicocelectomy, semen volume, spermatozoa concentration, and progressive motile spermatozoa proportion increased significantly in the postoperative period (p = 0.002, p = 0.006, p = 0.001, respectively). No significant change was found in the proportion of spermatozoa with normal morphology (p = 0.617). The changes in semen analysis data from the preoperative period to the third and sixth postoperative months after varicocelectomy with conventional and pulling techniques were compared. No significant difference was found between the two techniques.

CONCLUSION

Subinguinal microsurgical varicocelectomy with the "pulling" technique may be a safe and effective treatment option with fewer vein ligations compared to the standard surgical method.

Status of sperm mitochondrial functions and DNA methylation in infertile men with clinical varicocele before and after treatment

Varicocele has been associated with reduced male fertility potential. Treatment modalities for varicocele improve semen parameters, yet more than 50% of cases remain infertile. Varicocele-induced heat and hypoxia stress may affect sperm mitochondrial functions, possibly leading to aberrant epigenetic modifications. This study includes 30 fertile men and 40 infertile men with clinical varicocele. The effect of varicocele treatment (antioxidant supplementation and or varicocelectomy) was evaluated after 3 months of treatment. Mitochondrial membrane potential (MMP) and intracellular reactive oxygen species (iROS) were measured by flow cytometry using JC-1 and DCFDA, respectively. mtDNA copy number and deletions were determined by PCR. DNA methylation was analysed by pyrosequencing. Present investigations suggest that infertile men with varicocele have abnormal semen parameters; significantly low MMP, high iROS, and high mtDNA copy number. Semen parameters were improved in a subset of men of both the treatment modalities; however, it was noted that varicocelectomy helped better in improving sperm parameters compared to antioxidant treatment. Both treatment modalities helped in reducing iROS and mtDNA copy number significantly; however, they were noneffective in improving MMP. Altered DNA methylation at mitochondria D loop and mitochondrial structure and function genes UQCRC2, MIC60, TOM22, and LETM1 (promoter region) were observed in varicocele group. The DNA methylation levels were restored after varicocele treatment; however, the restoration was not consistent at all CpG sites. Both the treatment modalities helped in restoring the altered DNA methylation levels of mitochondrial genes but the restoration is nonhomogeneous across the studied CpG sites.

Predictability of varicocele repair success: preliminary results of a machine learning-based approach

ABSTRACT

Varicocele is a prevalent condition in the infertile male population. However, to date, which patients may benefit most from varicocele repair is still a matter of debate. The purpose of this study was to evaluate whether certain preintervention sperm parameters are predictive of successful varicocele repair, defined as an improvement in total motile sperm count (TMSC). We performed a retrospective study on 111 patients with varicocele who had undergone varicocele repair, collected from the Department of Endocrinology, Metabolic Diseases and Nutrition, University of Catania (Catania, Italy), and the Unit of Urology at the Selcuk University School of Medicine (Konya, Türkiye). The predictive analysis was conducted through the use of the Brain Project, an innovative tool that allows a complete and totally unbiased search of mathematical expressions that relate the object of study to the various parameters available. Varicocele repair was considered successful when TMSC increased by at least 50% of the preintervention value. For patients with preintervention TMSC below 5 × 10 6 , improvement was considered clinically relevant when the increase exceeded 50% and the absolute TMSC value was >5 × 10 6 . From the preintervention TMSC alone, we found a model that predicts patients who appear to benefit little from varicocele repair with a sensitivity of 50.0% and a specificity of 81.8%. Varicocele grade and serum follicle-stimulating hormone (FSH) levels did not play a predictive role, but it should be noted that all patients enrolled in this study were selected with intermediate- or high-grade varicocele and normal FSH levels. In conclusion, preintervention TMSC is predictive of the success of varicocele repair in terms of TMSC improvement in patients with intermediate- or high-grade varicoceles and normal FSH levels.

Effects of Varicocele Repair on Testicular Endocrine Function: A Systematic Review and Meta-Analysis

PURPOSE

The objective of this manuscript is to assess the effect of varicocele repair (VR) in patients with clinical varicoceles on serum total testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and inhibin B serum levels.

MATERIALS AND METHODS

The study was performed in compliance with the Meta-Analysis and Systematic Reviews of Observational Studies (MOOSE) guidelines and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). All eligible studies were selected following the PICOS (Population, Intervention, Comparison/Comparator, Outcomes, Study design) model. The values of each outcome measured after VR were compared to the before parameters and, when available, to the values on patients with unrepaired varicocele, and to those of healthy controls with no varicocele. For total testosterone, the values were sub-analyzed based on the mean total testosterone levels before VR (<300 ng/dL or >300 ng/dL), the fertility status, the time of follow-up and the technique used for VR.

RESULTS

From a total of 460 abstracts retrieved, 48 articles were included in our meta-analysis. Serum total testosterone levels were significantly higher after VR compared to both pre-treatment levels (mean difference [MD] 82.45 ng/dL, 95% confidence interval [CI]: 64.14-100.76; p<0.00001) and to the levels of patients with unrepaired varicocele (MD 91.64 ng/dL, 95% CI: 62.30-120.99; p<0.00001). They did not differ from the levels of healthy controls with no varicocele (MD -22.01 ng/dL, 95% CI: -68.59-24.58; p=0.35). The increase resulted to be independent from the mean total testosterone levels before VR, fertility status, time of follow-up and type of VR. After VR, a trend toward lower serum LH levels was found compared to before values (MD -0.37 IU/L, 95% CI: -0.74-0.01; p=0.06). When compared to the levels of patients with unrepaired VR, LH levels after VR were significantly lower (MD -0.96 IU/L, 95% CI: -1.56 to -0.35; p=0.002). LH levels were not significantly higher than healthy men without varicocele (MD 0.84 IU/L, 95% CI: -0.68-2.36; p=0.28). Patients with VR had significantly lower FSH levels compared to their pre-treatment values (MD -1.43 IU/L, 95% CI: -1.82 to -1.04; p<0.00001), and also to those of patients with non-repaired varicocele (MD -2.35 IU/L, 95% CI: -4.06 to -0.65; p=0.007). When compared to healthy controls with no varicocele, FSH levels were significantly higher (MD 2.71 IU/L, 95% CI: 1.12-4.31; p=0.0009). Lastly, after VR no significant change in inhibin B serum levels was seen compared to pre-treatment levels (MD 11.76 pg/mL, 95% CI: -3.83-27.35; p=0.14).

CONCLUSIONS

The present meta-analysis is the largest to date to assess the impact of VR on Leydig cell and Sertoli cell function using a before-after analysis for uncontrolled studies, and using data from patients with unrepaired varicoceles or healthy patients without varicocele as controls. VR was found to increase and restore to normality serum levels of total testosterone and LH. This evidence could be of value in considering the treatment of varicocele in patients with low testosterone or those who show a progressive decline in testosterone levels.

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.

From pathophysiology to practice: addressing oxidative stress and sperm DNA fragmentation in Varicocele-affected subfertile men

Varicocele can reduce male fertility potential through various oxidative stress mechanisms. Excessive production of reactive oxygen species may overwhelm the sperm's defenses against oxidative stress, damaging the sperm chromatin. Sperm DNA fragmentation, in the form of DNA strand breaks, is recognized as a consequence of the oxidative stress cascade and is commonly found in the ejaculates of men with varicocele and fertility issues. This paper reviews the current knowledge regarding the association between varicocele, oxidative stress, sperm DNA fragmentation, and male infertility, and examines the role of varicocele repair in alleviating oxidative-sperm DNA fragmentation in these patients. Additionally, we highlight areas for further research to address knowledge gaps relevant to clinical practice.

Comparison of SPAG11A gene expression in infertile men with grade 1 and 2 varicocele before and after treatment

OBJECTIVE

Sperm Associated Antigen 11A (SPAG11A) protein is a family of the epididymis-specific secretory proteins implicated in sperm maturation and function. Varicocele might cause pathophysiological difficulties in the testis and epididymis, with a harmful effect on the environment for spermatogenesis and sperm maturation. The aim of this study was to evaluate the expression level of the SPAG11A gene and sperm parameters in infertile men with grade 1 and 2 varicocele before and after treatment.

METHODS

Semen specimens were collected from 20 infertile men with varicocele pre-and post-treatment and 10 healthy volunteers. Semen analysis was conducted according to world health organization guidelines. Real time PCR (qRT-PCR) reaction was applied for determination of SPAG11A mRNA expression.

RESULTS

The results showed that there was a significant difference between the concentration and normal morphology between pre- and post-treatment groups and the controls. There were significant differences between pre-treatment and control groups in terms of progressive and non-progressive mobility. SPAG11A mRNA levels were significantly lower in the pre-treatment group than in healthy control subjects (p=0.007). There was no statistically significant difference in the expression of SPAG11A as well as semen parameters in the post-treatment group compared to the pre-treatment group.

CONCLUSIONS

SPAG11A gene expression and semen parameters may be affected by varicocele. Whether varicocele treatment is an effective approach to reduce the adverse effect of this disease on SPAG11A expression and semen parameters needs further investigation.

Effect of varicocele and varicocelectomy on sperm deoxyribonucleic acid fragmentation rates in infertile men with clinical varicocele

Varicocele is the leading cause of male infertility. It can affect sperm quantity and quality through various non-mutually exclusive pathophysiological mechanisms, mainly oxidative stress. Excessive production of reactive oxygen species may overwhelm the sperm's defenses against oxidative stress and harm the sperm's DNA. Excessive sperm DNA breaks, so-called sperm DNA fragmentation, result from the oxidative stress cascade and are commonly found in the ejaculates of men with varicocele and fertility-related issues. Measuring sperm DNA fragmentation can provide valuable information on the extent of harm and might help select candidates for surgical treatment. Varicocelectomy is beneficial for alleviating oxidative stress-associated infertility and improving sperm DNA integrity. However, reproductive outcomes of infertile men with elevated sperm DNA fragmentation rates and surgically treated varicoceles remain poorly studied, and there is a need for well-designed trials to determine the impact of sperm DNA fragmentation reduction on natural and medically assisted reproduction.

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.

A comparison of loupe-assisted and non-loupe-assisted subinguinal varicocelectomy

Introduction

Varicocele is a treatable aetiology of male infertility. Magnification with surgical loupe has been associated with improved outcome and reduced morbidity than the conventional technique without magnification.

Objective

To compare the outcomes of two techniques of subinguinal varicocelectomy, with a surgical loupe and without.

Patients and Methods

This was a prospective randomised hospital-based study. Forty-six patients were randomised to two arms - Group A: loupe-assisted subinguinal varicocelectomy (LASV) and Group B: open subinguinal varicocelectomy without Loupe (OSV). They all had their semen and hormonal parameters compared preoperatively and at 3 and 6 months postoperatively. Post-operative complications were also assessed. P < 0.05 was considered statistically significant.

Results

The mean age was 38.28 ± 4.55 years with a range of 27-46 years. The mean age in Group A was 37.35 ± 4.68 and 39.22 ± 4.33 years in Group B. There was an improvement in motility, sperm count and concentration in both the groups at 3 and 6 months (P < 0.05). However, there was no difference in these parameters on comparison of the two groups at 3 and 6 months (P > 0.05). Follicle-stimulating hormone decline was significant in the OSV group at 3 and 6 months, P = 0.010 and 0.021, respectively. There was no difference in other hormonal parameters both at 3 and 6 months (P > 0.05). The pregnancy rate in each arm of study was 4.3%. All complications occurred in Group B.

Conclusion

Both techniques resulted in improvement in seminal fluid parameters. All complications occurred in the arm that had subinguinal varicocelectomy without loupe. Loupe-assisted subinguinal varicocelectomy is safe and effective.

Efficacy of varicocelectomy on semen parameters and conception rates

Objective

Varicocele, the dilation of the pampiniform plexus of the spermatic cord. It is discovered incidentally in most patients. Symptoms vary, but its impact is especially experienced in the field of fertility and reflected in semen parameters. Varicocelectomy is a surgical approach to correct the varicocele, however, reports are conflicting regarding its success. Our aim was to evaluate the efficacy of varicocelectomy on semen parameters and conception rates in patients who underwent surgery and its association with comorbidities such as diabetes, hypertension, and obesity.

Materials and Methods

This cross-sectional study included the complete medical records of 86 patients. Data collection form included the patient's age, body mass index (BMI), chronic diseases, smoking, surgical history, medication usage, and the reason for performing surgery. Presurgical and postsurgical semen parameters were evaluated 3 months before surgery and an average of 6 months postoperatively. Data were analyzed with SPSS, Chi-square test, and independent and paired t-test.

Results

No significant difference was found between primary and secondary infertility regarding semen analysis, postoperative semen analysis indicated an improvement in semen motility at 180 min with no effect on other parameters. Using spontaneous intercourse or in vitro fertilization (IVF) after varicocelectomy was significantly associated with increasing conception rates irrespective of the type of infertility. Diabetes, hypertension, BMI, and smoking did not appear to affect semen parameters.

Conclusion

Patients who underwent varicocelectomy had improved sperm motility at 180 min and subsequently had a higher chance of successful conception either through spontaneous intercourse or IVF. Further studies are needed to understand the relationship between conception and sperm motility. Semen parameters were not affected if the patient had comorbidities such as diabetes and hypertension. Furthermore, smoking and BMI did not appear to affect the conception rate.

Impact of body mass index on semen parameters and reproductive hormones among men undergoing microsurgical subinguinal varicocelectomy

Background

Few studies assessed the relationships between BMI and post varicocelectomy semen quality and fertility potential and they reported inconsistent findings.

Objective

To assess the association of BMI with semen parameters and reproductive hormones before and after microsurgical varicocelectomy.

Materials and Methods

Retrospective chart review in a tertiary infertility center. Of 1170 patients with clinical varicocele during the study period (8 years), 813 patients were eligible and included. Patients were grouped into: Group A (kg/m2, n = 251 patients), B (BMI 25-29.9 kg/m2, n = 289), C (BMI 30-34.9 kg/m2, n = 183) and D (kg/m2, n = 90). Clinical data, semen parameters, sperm DNA fragmentation and hormonal profile were collected before and 3 months after microsurgical varicocelectomy.

Results

Patients' mean age was 35.87 ± 8.17 years. Higher-grade varicocele was significantly more prevalent in the lower BMI groups. BMI was significantly negatively correlated with preoperative sperm concentration, total motility progressive motility and total motile sperm count. Pre-operatively, sperm concentration, total motility, progressive motility and total motile sperm count showed significant differences between BMI groups, where higher BMI (Groups C and D) exhibited the poorest semen parameters. Postoperatively, all groups showed significant improvement in sperm concentration compared with pre-operative values. However, total and progressive motility were significantly improved in Groups A, B and C, while in Group D (highest BMI), total motility improved clinically but not statistically, progressive motility did not display improvement, and total motile sperm count was significantly improved only in Groups B and C. Postoperatively, mean improvements in semen parameters across the BMI groups were not significantly different, except for morphology, which improved significantly more in the less obese patients.

Conclusion

For infertile patients with clinical varicocele undergoing micro-surgical varicocelectomy, BMI appears not to impact the improvements across most of the semen parameters and hormones. The procedure might improve the fertility potential.

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.

Prediction of semen analysis parameter improvement after varicocoelectomy using 1 H NMR-based metabonomics assays

BACKGROUND

Varicocoele is the most common correctable cause of male infertility; however, predicting varicocoelectomy outcomes is difficult. "Omics" techniques have been increasingly used to develop new diagnostic and prognostics tools for several male infertility causes, and could be applied to study varicocoele.

OBJECTIVES

The objective is to create metabolomics models capable of segregating men who improved semen analysis (SA) parameters or achieved natural pregnancy after microsurgical varicocoelectomy (MV) from those who did not, using hydrogen-1 nuclear magnetic resonance (1 H NMR) spectra of seminal plasma of pre-operative samples.

MATERIAL AND METHODS

We recruited 29 infertile men with palpable varicocoele. 1 H NMR spectra of seminal plasma were obtained from pre-operative samples and used to create metabonomics models. Improvement was defined as an increase in the total motile progressive sperm count (TMC) of the post-operative SA when compared to the baseline, and pregnancy was assessed for 24 months after MV.

RESULTS

Using linear discriminant analysis (LDA), we created a model that discriminated the men who improved SA from those who did not with accuracy of 93.1%. Another model segregated men who achieved natural pregnancy from men who did not. We identified seven metabolites that were important for group segregation: caprylate, isoleucine, N-acetyltyrosine, carnitine, N-acetylcarnitine, creatine, and threonine.

DISCUSSION

We described the use of metabonomics model to predict with high accuracy the outcomes of MV in infertile men with varicocoele. The most important metabolites for group segregation are involved in energy metabolism and oxidative stress response, highlighting the pivotal role of these mechanisms in the pathophysiology of varicocoele.

CONCLUSIONS

1 H NMR spectroscopy of seminal plasma can be used in conjunction with multivariate statistical tools to create metabonomics models useful to segregate men with varicocoele based on the reproductive outcomes of MV. These models may help counseling infertile men with varicocoele regarding their prognosis after surgery.

Developing a novel prediction model for the impact of varicocelectomy on postoperative fertility

The objective of this study was to evaluate inflammatory markers as predictors of fertility after varicocelectomy and to develop a prediction model. This prospective cohort was conducted on patients with varicoceles who were presented to the clinic of Imam Reza hospital of Tehran during 2019-2020. Semen analysis, complete blood count (CBC), and scrotal ultrasonography was requested. Patients with abnormalities of semen analysis were chosen as candidates for varicocelectomy. 6 months after the operation, semen analysis was repeated. Hematologic and semen analysis parameters were recorded at baseline and follow-up visits. Treatment success was defined as 50% increase in total motile sperm count (TMSC) in cases with preoperative TMSC> 5 million/cc or 100% increase in TMSC in cases with preoperative TMSC< 5 million/cc. Patients were then categorized into two groups based on treatment success and statistical analysis was performed on these two groups. 124 infertile patients with varicocele were evaluated in our study. 52 patients (41.93%) showed improvements in semen analysis after varicocelectomy. After univariate and multivariate analysis three parameters were used in our predictive model as body mass index (BMI)>23.70 kg/m2 (4 scores), neutrophil-lymphocyte ratio (NLR) >1.80 (3 scores), and TMSC<14.69 million (2 scores). A cut-off value of 5 was associated with an 87.5% sensitivity and an 84.6% specificity for the prediction of failure of varicocelectomy. Varicocelectomy can improve semen analysis parameters in almost all infertile men with varicocele. Using BMI, NLR, and baseline TMSC as the suggested scoring system can predict the success of varicocelectomy for improving fertility and determine the appropriate infertile candidates for surgery.

Necrozoospermia: The tree that hides the forest

BACKGROUND

Necrozoospermia is a condition found in 0.2 to 0.4 % of male infertility cases. The causes of necrozoospermia are multiple: they can be related to testicular and/or post-testicular damage. Additionally, these causes most often involve the production of reactive oxygen species (ROS) and/or sperm DNA fragmentation (SDF) which can reduce the chances of spontaneous pregnancy or affect the outcome of assisted reproductive technologies.

OBJECTIVE

To focus on potential etiologies of necrozoospermia, its diagnosis and its therapeutic management especially before the employment of ICSI.

METHODS

Authors searched PubMed/Medline, Web of Science, Cochrane Library, Google and Institutional websites for medical subheading terms and free text words referred to "necrozoospermia", "sperm vitality", "sperm viability", "sperm DNA fragmentation" and "ICSI".

RESULTS

We identified twelve main etiologies of necrozoospermia responsible for either a decrease of sperm vitality, a mild a moderate or a severe necrozoospermia. In case of a confirmed decreased vitality, a thorough check-up should be conducted and if available, etiological treatment should be proposed. Therapeutic management could also include repeated ejaculations, drug treatments, the use of ICSI with ejaculated or surgically extracted spermatozoa in case of a non-treatable necrozoospermia.

DISCUSSION AND CONCLUSION

The potential causes of necrozoospermia should be investigated because many of them could be corrected, thus avoiding the use of ICSI. Moreover, if ICSI procedure remains necessary, the therapeutic management of necrozoospermia could also improve the chances of success by reducing oxidative stress and/or sperm DNA fragmentation. This article is protected by copyright. All rights reserved.

Artificial Intelligence Based Machine Learning Models Predict Sperm parameter Upgrading after Varicocele Repair: A Multi-Institutional Analysis

PURPOSE

Varicocele repair is recommended in the presence of a clinical varicocele together with at least one abnormal semen parameter, and male infertility. Unfortunately, up to 50% of men who meet criteria for repair will not see meaningful benefit in outcomes despite successful treatment. We developed an artificial intelligence (AI) model to predict which men with varicocele will benefit from treatment.

MATERIALS AND METHODS

We identified men with infertility, clinical varicocele, and at least one abnormal semen parameter from two large urology centers in North America (Miami and Toronto) between 2006 and 2020. We collected pre and post-operative clinical and hormonal data following treatment. Clinical upgrading was defined as an increase in sperm concentration that would allow a couple to access previously unavailable reproductive options. The tiers used for upgrading were: 1-5 million/mL (ICSI/IVF), 5-15 million/mL (IUI) and >15 million/mL (natural conception). Thus moving from ICSI/IVF to IUI, or from IUI to natural conception, would be considered an upgrade. AI models were trained and tested using R to predict which patients were likely to upgrade after surgery. The model sorted men into categories that defined how likely they were to upgrade after surgery (likely, equivocal, and unlikely).

RESULTS

Data from 240 men were included from both centers. A total of 45.6% of men experienced an upgrade in sperm concentration following surgery, 48.1% did not change, and 6.3% downgraded. The data from Miami were used to create a random forest model for predicting upgrade in sperm concentration. On external validation using Toronto data, the model accurately predicted upgrade in 87% of men deemed likely to improve, and in 49% and 36% of men who were equivocal and unlikely to improve, respectively. Overall, the personalized prediction for patients in the validation cohort was accurate (AUC 0.72).

CONCLUSIONS

A machine learning model performed well in predicting clinically meaningful post-varicocelectomy sperm parameters using pre-operative hormonal, clinical, and semen analysis data. To our knowledge, this is the first prediction model to show the utility of hormonal data, as well as the first to use machine learning models to predict clinically meaningful upgrading. This model will be published online as a clinical calculator that can be used in the preoperative counseling of patients.

The yield of microscopic varicocelectomy in men with severe oligospermia

Introduction:

Varicocele is detected in 35%–50% of men with primary infertility and up to 81% with secondary infertility. Various studies have shown that varicocele is related to testicular hypotrophy and impaired spermatogenesis. The effect of varicocelectomy in mild-to-moderate male factor infertility has been well reported. However, only a few studies addressed the impact of varicocelectomy in severe oligospermia.

Methods:

We included 45 patients with severe oligospermia (<5 million/mL) who underwent microsurgical varicocelectomy between May 2014 and November 2017. Results of semen analysis taken at 6 months after varicocelectomy were compared and patients were divided into responders and nonresponders. Chi-square was used to compare the preoperative and postoperative sperm count, motility, and volume.

Results:

After 6 months only one patient was found to be a responder with a pre- to post-operative motility of 45%–74% and a sperm concentration of 1 million/mL to 28.1 million/mL. There was a significant improvement in the mean sperm concentration after varicocelectomy which improved from 1.31 million/mL to 5.32 million/mL. However, a significant decrease in sperm motility was noted which decreased from 35.62% to 28.64% postoperatively. Postoperative semen volume increased from 2.56 mL to 3.19 mL, but this difference was not found to be statistically significant (P > 0.05). Four patients (8.9%) were found to have azoospermia after a 6-month follow-up. In these four patients who turned azoospermic had count <50,000 sperm/mL, two of them had a history of cryptospermia before varicocelectomy. Ejaculate sperm returned in two of these four patients in long-term follow-up (>6 months).

Conclusion:

The magnitude of improvement after microsurgical varicocelectomy for severely oligospermic patients is less profound than reported in mild male factor infertility.

What is the role of pre-operative blood parameters in forecasting varicocelectomy success?

BACKGROUND

We aimed to examine the effects of pre-operative blood values on varicocelectomy success.

MATERIALS AND METHODS

A total of 130 patients who underwent varicocelectomy in our clinic were retrospectively analyzed. Operation success was defined as the return of all semen parameters (concentration, progressive motility, and morphology) to normal values 6 months after surgery. The patients were separated as two groups as benefiting from the treatment (Group A) and not (Group B).

RESULTS

The best cut-off value for the neutrophil/lymphocyte ratio (NLR), which can predict varicocelectomy success, was assigned to be 2.27, with AUC of 0.859 (%95 CI 0.795-0.922). The highest sensitivity and specificity were 0.857 and 0.731 (p < 0.001). The best cut-off value for the mean platelet volüme (MPV) value, which can predict varicocelectomy success, was assigned to be 9.45, with AUC of 0.729 (%95 CI 0.639-0.819). The highest sensitivity and specificity were 0.655 and 0.635 (p < 0.001). Binary logistic regression analysis showed NLR ratio (odds ratio (OR): 11.2, p < 0.001) and MPV (OR: 2.65, p = 0.002) parameters as independent predictive factors in predicting varicocelectomy success.

DISCUSSION AND CONCLUSION

Our study showed that low NLR ratio (≤2.27) and high MPV (≥9.45) ratio levels may be a useful pre-operative predictive tool in identifying men who benefit most from varicocelectomy in infertile patients with varicocoele.

Current Insights and Latest Updates in Sperm Motility and Associated Applications in Assisted Reproduction

Spermatozoon is a motile cell with a special ability to travel through the woman’s reproductive tract and fertilize an oocyte. To reach and penetrate the oocyte, spermatozoa should possess progressive motility. Therefore, motility is an important parameter during both natural and assisted conception. The global trend of progressive reduction in the number and motility of healthy spermatozoa in the ejaculate is associated with increased risk of infertility. Therefore, developing approaches for maintaining or enhancing human sperm motility has been an important area of investigation. In this review we discuss the physiology of sperm, molecular pathways regulating sperm motility, risk factors affecting sperm motility, and the role of sperm motility in fertility outcomes. In addition, we discuss various pharmacological agents and biomolecules that can enhance sperm motility in vitro and in vivo conditions to improve assisted reproductive technology (ART) outcomes. This article opens dialogs to help toxicologists, clinicians, andrologists, and embryologists in understanding the mechanism of factors influencing sperm motility and various management strategies to improve treatment outcomes.

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.

Etiologies of sperm DNA damage and its impact on male infertility

Male factor is responsible for up to 50% of infertility cases in the world. Semen analysis is considered the cornerstone of laboratory evaluation of male infertility, but it has its own drawbacks and fails to predict the male fertility potential with high sensitivity and specificity. Different etiologies have been linked with male infertility, of which sperm DNA damage has gained significant attention with extensive research on sperm function tests. The associations between sperm DNA damage and a variety of disorders such as varicocele, obesity, cancer, radiation and lifestyle factors are explored in this review. Furthermore, we discuss the mechanisms of DNA damage as well as its impact in different scenarios of male infertility, associated with spontaneous and assisted reproduction. Finally, we review the clinical applicability of sperm DNA fragmentation testing in the management of male infertility.

Protein profiling in unlocking the basis of varicocele-associated infertility

Varicocele is one of the major causes of male infertility and has a negative impact on spermatogenesis. The conventional semen analysis does not reveal the underlying subcellular mechanisms associated with defects in spermatozoa. Proteomics and bioinformatics analysis can be used to identify the molecular aetiologies associated with poor semen quality in varicocele patients. Mitochondrial dysfunction has been identified as the main factor affecting normal physiological functions of spermatozoa. This article discusses the proteomic studies of spermatozoa and seminal plasma in varicocele patients. Proteomics can identify potential spermatozoa and seminal plasma biomarkers in varicocele-mediated male infertility. In future, these protein biomarkers can be useful in the development of noninvasive diagnostic and therapeutic strategies for varicocele patients.

Conventional semen analysis and advanced sperm function tests in diagnosis and management of varicocele

Clinical varicoceles are a common cause of male infertility and affect sperm parameters as measured in a conventional semen analysis. Varicocelectomy has been shown in prospective studies to improve semen parameters in men with a clinical varicocele. Clinical varicoceles are also a well-known source of oxidative stress which may affect the quality of spermatozoa. Spermatozoa are particularly susceptible to oxidative stress due to a limited capacity for DNA repair. The susceptibility of spermatozoa to oxidative stress is modulated by a balance between ROS and antioxidants, which can be quantified by various laboratory assays. Varicocelectomy has been consistently shown to reduce both ROS and sperm DNA fragmentation, and various assays should be utilised in the diagnosis and treatment of infertile men with a clinical varicocele.

Preoperative follicle-stimulating hormone: A factor associated with semen parameter improvement after microscopic subinguinal varicocelectomy

INTRODUCTION

Currently, there exists no serum biomarker to predict patients likely to benefit from varicocelectomy. The purpose of this study was to assess the association between baseline follicle-stimulating hormone (FSH) and semen parameter changes after subinguinal microscopic varicocelectomy.

METHODS

We retrospectively reviewed all men who underwent microscopic subinguinal varicocelectomy between August 2015 and October 2018. Pre- and postoperative semen analyses were stratified per total motile sperm count (TMSC): TMSC <5, 5-9, and >9 million (based on TMSC required for in vitro fertilization, intrauterine insemination [IUI], and natural conception, respectively). Then, variables were analyzed to determine the correlation with postoperative TMSC values and upgrade in TMSC category.

RESULTS

Among the 66 men analyzed, 55 (83.3%) and 11 (16.7%) had a preoperative TMSC of <5 million and 5-9 million, respectively. A total of 33 (50%) patients upgraded in TMSC category, 26 of them achieving levels corresponding to natural conception and seven achieving those of IUI. Additionally, a significant correlation was observed between postoperative TMSC and preoperative TMSC (r=0.528; p<0.001), and preoperative FSH (r=-0.314; p=0.010). A lower preoperative FSH (odds ratio [OR] 0.82; 95% confidence interval [CI] 0.68-0.98; p=0.028) and a higher preoperative TMSC (OR 1.37; 95% CI 1.06-1.76; p=0.015) were associated with upgrade in TMSC category.

CONCLUSIONS

Lower preoperative FSH and higher TMSC are associated with improvement in TMSC category after varicocelectomy, although small sample size limited the study. FSH can be useful to identify men who are most likely to benefit from varicocele repair.

Progressive sperm motility is associated with spontaneous pregnancy after varicocelectomy

Background: Varicocelectomy is performed on patients with clinical varicocele associated with abnormal sperm parameters. The goal of this procedure is to improve men’s sperm parameters and pregnancy rates of their partners. The objective of our study was to assess the factors that were associated with spontaneous pregnancy in female partners after varicocelectomy.Methods: A retrospective case-control study was conducted to review several factors that are associated with spontaneous pregnancy after varicocelectomy. The data were taken from medical records at Sanglah General Hospital and three private hospitals in Denpasar from January 2015 to June 2016. Case subjects (n=38) include varicocele patients with abnormal sperm parameters whose partner had a spontaneous pregnancy following varicocelectomy and a control group (n=38) whose partner did not have a spontaneous pregnancy following varicocelectomy.Results: Progressive sperm motility (≥37.5%) before varicocelectomy was 2.7 times more likely to result in a spontaneous pregnancy (odds ratio: 2.7; 95% confidence interval: 1.04–6.96; p=0.04). No statistical significance was found between age at varicocelectomy, grade of varicocele, body mass index, infertility duration, smoking habit, sperm concentration, normal sperm morphology before varicocelectomy, and spontaneous pregnancy.Conclusion: Progressive sperm motility before varicocelectomy is a significant factor for the occurrence of spontaneous pregnancy after varicocelectomy.

[Necrozoospermia: From etiologic diagnosis to therapeutic management]

This review describes necrospermia, its diagnosis, causes and management. Sperm vitality is commonly assessed in the laboratory of reproductive biology, with the eosin test or with the hypo-osmotic swelling test. Necrospermia is defined by a percentage of living spermatozoa inferior to 58%, and can be related to male infertility. Several pathological mechanisms may be involved and can be classified either in testicular causes (hyperthyroidism, local hyperthermia, varicocele), or post-testicular causes (epididymal necrospermia, dysregulation of seminal plasma, adult polycystic kidney disease, vasectomy reversal, anti-sperm antibodies) or both (infection, toxic, age, spinal cord injury). The first treatment is to correct the underlying cause, if possible. Repetitive ejaculation has demonstrated to be effective as well. Many drugs would also improve the sperm vitality (antioxidants, non-and-steroidal anti-inflammatory drugs) but there is currently no guideline to recommend their use. With necrospermia, fertilization rates are lower but in vitro fertilization (IVF) with Intracytoplasmic sperm injection (ICSI) improves the chances of conception.

Effects of varicocelectomy on serum testosterone

Varicocele is most often surgically repaired due to male infertility, however, has recently been linked to low serum testosterone. This paper serves to review the current literature regarding varicocele and its subsequent repair on serum testosterone. Twenty-eight human studies were identified with fifteen showing improved serum testosterone after repair. The majority of the studies that demonstrated improvement had preoperative testosterone levels that were low or below normal. Additionally, multiple well-designed studies with control groups not undergoing surgical repair demonstrated significant difference between groups. This improvement was less observed in studies with normal preoperative serum testosterone. A majority of these patients studied were presenting for infertility. It remains to be determined if these findings can be reproduced in men without infertility. The findings suggest that microsurgical varicocele repair can improve serum testosterone in men with low levels preoperatively in appropriately counseled men. It remains to be seen whether varicocele repair can help prevent the development of low testosterone in the future or which patients are at risk of developing low testosterone due to varicocele.

Treatment effect of TUSPLV on recurrent varicocele

The aim of the study was to analyze the treatment effect of transumbilical single-port laparoscopic varicocelectomy (TUSPLV) on recurrent varicocele (VC). In order to compare the surgical effects of TUSPLV to traditional retroperitoneal ligation of the internal spermatic vein, 64 patients with recurrent VC were enrolled and divided into the control group (n=30) and the observation group (n=34). Patients in the control group underwent surgery using traditional retroperitoneal ligation of the internal spermatic vein, while those in the observation group underwent surgery using TUSPLV. The results showed that the time of operation and bleeding volume in the observation group were significantly lower. The occurrence and recurrence rates of periprocedural complications were considerably lower in the observation group. Differences were statistically significant (P<0.05). In terms of the pregnancy rate, the difference between the 2 groups had no statistical significance (P>0.05). We concluded that employing TUSPLV to treat recurrent VC was safe and effective.

Preoperative duplex ultrasound parameters predicting male fertility after successful varicocelectomy

OBJECTIVES

To assess duplex ultrasound (DUS) parameters, and predicti the outcome of varicocele ligation in male infertility. 

METHODS

This retrospective and follow up study was conducted at Dr. Sulaiman Al Habib Hospital, AlQassim, Saudi Arabia between January 2011 and December 2012. Eighty-two patients were selected, who presented with clinical/subclinical varicocele and male infertility. All these patients had DUS of the scrotum and underwent for low ligation varicocelectomy. These patients were followed for a period of 12-24 months after surgery for the occurrence of paternity. We reviewed pre-operative scrotal DUS of these 82 patients for the testicular size and volume, pampiniform veins caliber and duration of reflux in the dilated veins at rest, and after valsalva maneuver. These DUS parameters were correlated with the postoperative paternity rate.  

RESULTS

Postoperative paternity was achieved in 18 patients (31.6%) with normal-sized testes, and in 3 patients (12%) with small size testes. The positive paternity rate was higher (38.5%) in patients with clinically detected varicocele, compared with only 16.7% of patients with subclinical varicocele (detected by ultrasound only). In addition, postoperative paternity was significantly higher in patients with bilateral varicocele (70.6%), with shunt-type varicocele (71.4%), and patients with a permanent grade of venous reflux (62.5%).  

CONCLUSION

Selection of patients for the successful paternity after varicocele repair depends mainly on DUS parameters, which includes normal size testicles with shunt type of bilateral varicocele and continuous reflux.

Varicocele - a case for early intervention

Testicular varicocele, which is defined as the dilation of the veins draining the testicle, has long been associated with a detrimental effect on testicular function. Despite a lack of high-quality, prospective data, recent evidence has shed light on potential links between varicocele and male infertility and serum testosterone levels. Similarly, varicocele repair has increasingly been shown to have a beneficial impact on pregnancy rates, semen parameters, and on improving serum testosterone in adult men. Numerous studies have assessed the optimal technique for varicocele repair and the bulk of the evidence has shown the microsurgical inguinal/subinguinal approach to have the highest success rates, the lowest overall complication rates, and the lowest recurrence rates. The management of varicocele in adolescents remains a clinical conundrum, but contemporary evidence suggests early deleterious effects of varicocele on testicular function in some patients. Well-designed prospective trials are critical to delineate the true impact and role of varicocele repair on male infertility and hypogonadism in adult and adolescent men.