3 Case Report 26y male with 1ry infertility of 3y. Examination: Bilateral normal testes, Bilateral grade II varicocele.Semen x2 Azooepermia, Volume 2-3cc, normal semen fructoseFSH was normal.Bilateral inguinal varicocelectomy, testicular biopsy:Hypospermatogenisis
4 18 months later one child Semen: Volume: 1.5 cc Conc.: 3 m/cc Motility: 25%
5 Varicocele 10-15% general population 40% 1ry infertility
6 Ambroïse Paré (1500–1590): a clinical problem Barfield, late 19th century: Relationship to infertilityLipshultz, 1979: Relationship to testicular atrophy that is progressive with ageKass and Belman, 1987:significant increase in testicular volume after varicocele repair in adolescents
7 Clinical study of varicocele: the results of long-term follow-up. Sixty-four infertile male patients with varicocele :Varicocelectomy 31 casesNo surgery 30 casesThe mean follow-up duration was 76.2 monthsThe pregnancy rate: (60%) VS (28%)Int J Urol Aug;9(8):
8 Surgery Vs Observation 146 men left varicocelectomy62 men refused surgery treated with tamoxipheneFollowed up for at least 1 yearImprovement in semen parameters:83.2% VS 32.3%Pregnancy within 1 year:62(46.6%) VS 8 (12.9%) (p<0.001).Eur Urol Mar;39(3):322-5.
9 Is varicocelectomy really beneficial in the treatment of male factor infertility?
10 Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. A meta-analysis was performed to evaluate both randomized controlled trials and observational studies using a new scoring system.Adjust and quantify for various potential sources of bias, including selection bias, follow-up bias, confounding bias, information or detection bias, and other types of bias, such as misclassificationOf 136 studies identified through the electronic and hand search of references, only 17 studies met our inclusion criteria
11 Statistically significant improvement in: …..continueStatistically significant improvement in:ConcentrationMotilityMorphologyCONCLUSIONS: Surgical varicocelectomy significantly improves semen parameters in infertile men with palpable varicocele and abnormal semen parameters.Agarwal A, Department of Obstetrics Gynecology, Cleveland Clinic Urology Sep;70(3):532-8
12 Daitch JA. J Urol. 2001 May;165(5):1510-3 Varicocelectomy Improves Intrauterine Insemination Success Rates in Men with Varicocele.24 pts intrauterine insemination cycles without varicocele treatment.34 pts intrauterine insemination cycles following varicocelectomy.No statistically significant difference was noted in the mean post-wash total motile sperm count in the treated and untreated groups.The pregnancy rate per cycle = 6.3 VS 11.8, p = 0.04Live birth rate per cycle =1.6 VS 11.8, p = 0.007Conclusion: A functional factor not measured on routine semen analysis may affect pregnancy rates in this settingDaitch JA. J Urol May;165(5):1510-3
13 Why Does Varicocelectomy Improve the Abnormal Semen Parameters? 68 infertile menSeminal plasma levels of two ROS and six antioxidants on the day prior to varicocelectomySame parameters were measured again 3 and 6 months post-operatively.concluded that varicocelectomy reduces ROS levels and increases antioxidant activity of seminal plasma from infertile men with varicocele.Conclusion: Varicocelectomy reduces ROS levels and increases antioxidant activity of seminal plasma from infertile men with varicocele.Mostafa T, Department of Andrology, Faculty of Medicine, Cairo University Int J Androl Oct;24(5):261-5.
14 Varicocele: a bilateral disease 286 infertile menPhysical examination, contact thermography, Doppler sonography, and venography of both testes.88.8% bilateralMean sperm concentration increased from / to / million/mLmean sperm motility from / to /- 1.41%mean sperm morphology from / to /- 1.17%.Pregnancy rate was 43.5%This may suggest that we should consider varicocele a bilateral diseaseGat Y. Fertil Steril Feb;81(2):424-9.
15 Is assisted reproduction the optimal treatment for varicocele-associated male infertility? A cost-effectiveness analysis.The cost per delivery with ICSI was found to be $89,091The cost per delivery after varicocelectomy was only $26,268The average published U.S. delivery rate after one attempt of ICSI was only 28%. whereas a 30% delivery rate was obtained after varicocelectomy.CONCLUSIONS: Specific treatment of varicocele-associated male factor infertility with surgical varicocelectomy is more cost-effective than primary treatment with assisted reproduction.Schlegel PN. Urology Jan;49(1):83-90
18 Consideration of sterility; subfertility in the male Interestingly, the first study on the importance of varicocelectomy to male infertility (Tulloch, 1952 ) reported spontaneous pregnancy after varicocele repair in an azoospermic manTulloch, W.S Edinb. Med. J , 59, 29–34.
19 Results of ligation of internal spermatic vein in the treatment of infertility in azoospermic patients.10 azoospermic patients2 pregnanciesMehan DJ. Fertil Steril Jan;27(1):110-4.
20 Inguinal Varcocelectomy in Azoospermic patients 13 azo inguinal varicocelectomyInduction of spermatogenesis was achieved in 3 (23%) patientsTwo of them had hypospermatogenesis and one had maturation arrest at spermatid stageNo pregnancies by natural intercourseCakan M. Arch Androl May-Jun;50(3):145-50
21 Sclerotherapy for Varicocele in Azoospermic patients 14 Azo sclerotherapy7/14 produced spermsSperm con 3.1 ± 1.2 × 106/mLMean sperm: 2.2 ± 1.9%mean sperm normal morphology: 7.8 ± 2.2%2 pregnanciesPoulakis V. Asian J Androl Sep;8(5):613-9.
22 Embolization of Varicocele 32 men with azoospermiaImproved in 18/32:sperm concentration in the ejaculate 3.81±1.69 x 106/mlmean sperm motility: 1.20±3.62%mean sperm morphology: 8.30±2.64Nine pregnancies (26%)Four (12%) unassistedFive (15%) by ICSIGat Y. Human Reproduction (4):
23 Is the Effect Durable? 27 azoospermia microsurgical varicocelectomy Induction of spermatogenesis was achieved in nine men (33.3%)Sperm conc 1.2 x 10(6)/mL to 8.9 x 10(6)/mLMotility 24% to 75.7%,One patient with maturation arrest established pregnancyFive relapsed into azoospermia 6 months after the recovery of spermatogenesisPasqualotto FF, Fertil Steril Mar;85(3):635-9.
24 How long does it take for the sperms to appear? 17 azo microsurSpermatozoa in the ejacultae 47% (8/17)Only 35% (6/17) of them had motile spermMean time for appearance of spermatozoa in the ejaculates was 5 months (3 to 9 months).Esteves SC. Int Braz J Urol Nov-Dec;31(6):541-8.
27 Response to varicocelectomy in oligospermic men with and without defined genetic infertility. 33 men with infertility & varicocele7 has coexisting genetic infertility:Abnormal karyotype in 4Y chromosome microdeletion in 326 No defectSame semen parametersAll had varicocelectomy54% VS 0% improvementCONCLUSIONS: From this early experience, men with varicocele and genetic lesions appear to have a poorer response to varicocele repair than men without coexisting genetic lesions.
28 Donkol RH. J Ultrasound Med. 2007 May;26(5):593-9. Paternity after varicocelectomy: preoperative sonographic parameters of success.What are the sonographic findings that could predict the outcome of varicocele repair in the treatment of male infertility?107 patients with varicocele.CONCLUSIONS: The best preoperative sonographic parameters of success of varicocele repair are:The presence of normal-sized testesClinically palpable veinsBilateral varicoceleDonkol RH. J Ultrasound Med May;26(5):593-9.
29 Relationship between varicocele size and response to varicocelectomy. grade 1--small (22 patients)grade 2--medium (44)grade 3--large (20)Sperm count, per cent motility, per cent tapered forms were measured preoperatively and postoperatively.Conclusion: infertile men with a large varicocele have poorer preoperative semen quality but repair of the large varicocele in those men results in greater improvement than repair of a small or medium sized varicocele.Goldstein M.J Urol Apr;149(4):769-71
30 Azoospermia: Predictors of Success FSHHistology
31 FSHPreoperative FSH levels between men who did (14.8 ± 3.1 IU/L) and did not (19.4 ± 3.8 IU/L) show improvement in semen parameters after sclerotherapy were not significantly differentCzplick M. Arch Androl. 1979;3(1):51-5
32 Histology Germinal Aplasia Maturation arrest at spermatocyte stage HypospermatogenisisMaturation arrest at spermatid stage
33 ….continue: predectors of success 13 Azoospermic patientsAgePreoperative sex hormonesUnilaterl VS BilateralVaricocele gradeHypospermatogenesis and late maturation arrestNo associationArch Androl May-Jun;50(3):145-50
34 TOTAL 275 108 (39.27%) Author Year No. of pts Tech. % of pts with spermsPregnancy(%)Czaplicki197933Micro12(34%)3 patientsMatthews19982212(55%)3PTSKadioglu2001245(20.8%)?Kim19992812(43%)2Schlegel2004317(22%)NilCakan13Inguin3(23%)Pasqualotto2006279(33.3)1Lee2007197(36.4%)Esteves2005178(47%)1 Spontan4 ICSIGat32Embo.18(56.2%)9(26%)Poulakis14Sclero7(50)Osmonov15sclerot8(53) all <0.1m/ccTOTAL275108 (39.27%)
35 Subclinical Varicocele subclinical in 73 patientsClinical in 66 patients, based on palpation in addition to ultrasonography.Conclusion: ligation of varicoceles detected using Doppler ultrasonography, whether palpable or not, results in an increase in sperm concentration and motility.Pierik FH, Rotterdam, The Netherlands. Int J Androl Oct;21(5):
36 76 underwent varicocele repair Improvement: Clinical VS subclinical:67% VS 41%But: Equal number were worse postoperatively and, thus, mean sperm count was unchanged for the group with subclinical varicoceleConclusion: The results of our study suggest that subclinical varicocelectomy is of questionable benefit.Jarow JP North Carolina, USA. J Urol Apr;155(4):
37 Aboulghar M. Fertil Steril. 1997 Jul;68(1):108-11 Fertilization and pregnancy rates after intracytoplasmic sperm injection using ejaculate semen and surgically retrieved sperm.350 patients:Ejaculated spermEpididymalTesticularCONCLUSION: The fertilizing ability of sperm in ICSI is highest with normal ejaculated semen and lowest with sperm extracted from a testicular biopsy in non-obstructive azoospermia.Aboulghar M. Fertil Steril Jul;68(1):108-11
38 ConclusionVaricocele may cause any variation of severity in spermogram including azoospermia.The treatment of varicocele may significantly improve spermatogenesis and renew sperm production.Adequate treatment may spare the need for TESE as preparation for ICSI in >30% of azoospermic patients.Since achievement of pregnancy in IVF units is higher when spermatogenesis is better, the treatment of varicocele is an effective medical adjunct for IVF units prior to the treatment.In men with spermatogenic failure, freshly ejaculated sperm are easier to use, and fertilization ability in ICSI is higher with normal semen than with sperm retrieved by TESE