Varicocele and male infertility

Soo Woong Kim

doi:10.5124/jkma.2012.55.1.37

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Kim: Varicocele and male infertility

Continuing Education Column

Journal of the Korean Medical Association

Journal of the Korean Medical Association 2012; 55(1): 37-46.

Published online: 11 January 2012

DOI: https://doi.org/10.5124/jkma.2012.55.1.37

Varicocele and male infertility

Soo Woong Kim, MD

Department of Urology, Seoul National University College of Medicine, Seoul, Korea.

Corresponding author: Soo Woong Kim, swkim@snu.ac.kr

Received 8 October 2011 Accepted 22 October 2011

(open-access):

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Varicoceles are the most frequent physical findings in infertile men. Although the varicocele is generally regarded to be the most common correctable cause of male infertility, whether varicocelectomy is an effective treatment for male factor infertility has been the focus of intense debate. A great deal of evidence indicates that varicocelectomy is clearly associated with a significant improvement in semen parameters (concentration, motility, and morphology). Varicocelectomy also appears to reduce seminal oxidative stress and sperm DNA damage. In contrast, the positive effect of varicocelectomy on improving natural pregnancy rates is less clear based on a few randomized controlled trials. Therefore, the need persists for well-designed, properly conducted randomized controlled trials to address this issue. Considering the beneficial effects of varicocelectomy on semen parameters, varicocelectomy should be considered in men with palpable lesions, at least one abnormal semen parameter and otherwise unexplained infertility. Microsurgical inguinal or subinguinal varicocelectomy techniques have been shown to result in fewer recurrences and postoperative complications than other techniques.

Keywords: Male infertility, Varicocele, Varicocelectomy

Figures and Tables

Table 1

Odds ratio and 95% confidence interval (CI) for pregnancy outcome in the four randomized controlled trials on varicocele repair or observation in men with abnormal semen parameters and clinical varicocele

References

1. World Health Organization. The influence of varicocele on parameters of fertility in a large group of men presenting to infertility clinics. Fertil Steril. 1992. 57:1289–1293.

2. Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril. 1993. 59:613–616.

3. Witt MA, Lipshultz LI. Varicocele: a progressive or static lesion? Urology. 1993. 42:541–543.

4. Paduch DA, Niedzielski J. Repair versus observation in adolescent varicocele: a prospective study. J Urol. 1997. 158(3 Pt 2):1128–1132.

5. Zampieri N, Mantovani A, Ottolenghi A, Camoglio FS. Testicular catch-up growth after varicocelectomy: does surgical technique make a difference? Urology. 2009. 73:289–292.

6. Yaman O, Ozdiler E, Anafarta K, Gogus O. Effect of microsurgical subinguinal varicocele ligation to treat pain. Urology. 2000. 55:107–108.

7. Karademir K, Senkul T, Baykal K, Aşte F, Işeri C, Erden D. Evaluation of the role of varicocelectomy including external spermatic vein ligation in patients with scrotal pain. Int J Urol. 2005. 12:484–488.

8. Tulloch WS. Varicocele in subfertility: results of treatment. Br Med J. 1955. 2:356–358.

9. MacLeod J. Seminal cytology in the presence of varicocele. Fertil Steril. 1965. 16:735–757.

10. Lipshultz LI, Thomas AJ Jr, Khera M. Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Surgical management of male infertility. Campbell-Walsh urology. 2007. 9th ed. Philadelphia: Saunders;654–717.

11. Dubin L, Amelar RD. Varicocelectomy: 986 cases in a twelve-year study. Urology. 1977. 10:446–449.

12. Agarwal A, Deepinder F, Cocuzza M, Agarwal R, Short RA, Sabanegh E, Marmar JL. Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology. 2007. 70:532–538.

13. Male Infertility Best Practice Policy Committee of the American Urological Association. Practice Committee of the American Society for Reproductive Medicine. Report on varicocele and infertility. Fertil Steril. 2004. 82:Suppl 1. S142–S145.

14. Practice Committee of American Society for Reproductive Medicine. Report on varicocele and infertility. Fertil Steril. 2008. 90:5 Suppl. S247–S249.

15. Dohle GR, Colpi GM, Hargreave TB, Papp GK, Jungwirth A, Weidner W. EAU Working Group on Male Infertility. EAU guidelines on male infertility. Eur Urol. 2005. 48:703–711.

16. Dahl EV, Herrick JF. A vascular mechanism for maintaining testicular temperature by counter-current exchange. Surg Gynecol Obstet. 1959. 108:697–705.

17. Goldstein M, Eid JF. Elevation of intratesticular and scrotal skin surface temperature in men with varicocele. J Urol. 1989. 142:743–745.

18. Shiraishi K, Takihara H, Matsuyama H. Elevated scrotal temperature, but not varicocele grade, reflects testicular oxidative stress-mediated apoptosis. World J Urol. 2010. 28:359–364.

19. Lund L, Nielsen KT. Varicocele testis and testicular temperature. Br J Urol. 1996. 78:113–115.

20. Mieusset R, Bujan L, Mondinat C, Mansat A, Pontonnier F, Grandjean H. Association of scrotal hyperthermia with impaired spermatogenesis in infertile men. Fertil Steril. 1987. 48:1006–1011.

21. Lerchl A, Keck C, Spiteri-Grech J, Nieschlag E. Diurnal variations in scrotal temperature of normal men and patients with varicocele before and after treatment. Int J Androl. 1993. 16:195–200.

22. Wright EJ, Young GP, Goldstein M. Reduction in testicular temperature after varicocelectomy in infertile men. Urology. 1997. 50:257–259.

23. Rajfer J, Turner TT, Rivera F, Howards SS, Sikka SC. Inhibition of testicular testosterone biosynthesis following experimental varicocele in rats. Biol Reprod. 1987. 36:933–937.

24. Ku JH, Shim HB, Kim SW, Paick JS. The role of apoptosis in the pathogenesis of varicocele. BJU Int. 2005. 96:1092–1096.

25. Wang C, Cui YG, Wang XH, Jia Y, Sinha Hikim A, Lue YH, Tong JS, Qian LX, Sha JH, Zhou ZM, Hull L, Leung A, Swerdloff RS. Transient scrotal hyperthermia and levonorgestrel enhance testosterone-induced spermatogenesis suppression in men through increased germ cell apoptosis. J Clin Endocrinol Metab. 2007. 92:3292–3304.

26. Agarwal A, Said TM. Oxidative stress, DNA damage and apoptosis in male infertility: a clinical approach. BJU Int. 2005. 95:503–507.

27. Sweeney TE, Rozum JS, Desjardins C, Gore RW. Microvascular pressure distribution in the hamster testis. Am J Physiol. 1991. 260(5 Pt 2):H1581–H1589.

28. Mali WP, Arndt JW, Coolsaet BL, Kremer J, Oei HY. Haemodynamic aspects of left-sided varicocele and its association with so-called right-sided varicocele. Int J Androl. 1984. 7:297–308.

29. Green KF, Turner TT, Howards SS. Varicocele: reversal of the testicular blood flow and temperature effects by varicocele repair. J Urol. 1984. 131:1208–1211.

30. De Lamirande E, Lamothe G. Reactive oxygen-induced reactive oxygen formation during human sperm capacitation. Free Radic Biol Med. 2009. 46:502–510.

31. Alvarez JG, Touchstone JC, Blasco L, Storey BT. Spontaneous lipid peroxidation and production of hydrogen peroxide and superoxide in human spermatozoa. Superoxide dismutase as major enzyme protectant against oxygen toxicity. J Androl. 1987. 8:338–348.

32. Mazzilli F, Rossi T, Marchesini M, Ronconi C, Dondero F. Superoxide anion in human semen related to seminal parameters and clinical aspects. Fertil Steril. 1994. 62:862–868.

33. Cocuzza M, Athayde KS, Agarwal A, Pagani R, Sikka SC, Lucon AM, Srougi M, Hallak J. Impact of clinical varicocele and testis size on seminal reactive oxygen species levels in a fertile population: a prospective controlled study. Fertil Steril. 2008. 90:1103–1108.

34. Lenzi A, Culasso F, Gandini L, Lombardo F, Dondero F. Placebo-controlled, double-blind, cross-over trial of glutathione therapy in male infertility. Hum Reprod. 1993. 8:1657–1662.

35. Cavallini G, Ferraretti AP, Gianaroli L, Biagiotti G, Vitali G. Cinnoxicam and L-carnitine/acetyl-L-carnitine treatment for idiopathic and varicocele-associated oligoasthenospermia. J Androl. 2004. 25:761–770.

36. Turek PJ, Lipshults LI. The varicocele controversies II. Diagnosis and treatment. AUA update series. 1995. Houston: American Urological Association;112–119.

37. Sze DY, Kao JS, Frisoli JK, McCallum SW, Kennedy WA 2nd, Razavi MK. Persistent and recurrent postsurgical varicoceles: venographic anatomy and treatment with N-butyl cyanoacrylate embolization. J Vasc Interv Radiol. 2008. 19:539–545.

38. Homonnai ZT, Fainman N, Engelhard Y, Rudberg Z, David MP, Paz G. Varicocelectomy and male fertility: comparison of semen quality and recurrence of varicocele following varicocelectomy by two techniques. Int J Androl. 1980. 3:447–458.

39. Niedzielski J, Paduch DA. Recurrence of varicocele after high retroperitoneal repair: implications of intraoperative venography. J Urol. 2001. 165:937–940.

40. Goldstein M, Gilbert BR, Dicker AP, Dwosh J, Gnecco C. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol. 1992. 148:1808–1811.

41. Marmar JL, Kim Y. Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data. J Urol. 1994. 152:1127–1132.

42. Cayan S, Kadioglu TC, Tefekli A, Kadioglu A, Tellaloglu S. Comparison of results and complications of high ligation surgery and microsurgical high inguinal varicocelectomy in the treatment of varicocele. Urology. 2000. 55:750–754.

43. Szabo R, Kessler R. Hydrocele following internal spermatic vein ligation: a retrospective study and review of the literature. J Urol. 1984. 132:924–925.

44. Hopps CV, Lemer ML, Schlegel PN, Goldstein M. Intraoperative varicocele anatomy: a microscopic study of the inguinal versus subinguinal approach. J Urol. 2003. 170(6 Pt 1):2366–2370.

45. Donovan JF, Winfield HN. Laparoscopic varix ligation. J Urol. 1992. 147:77–81.

46. Baazeem A, Belzile E, Ciampi A, Dohle G, Jarvi K, Salonia A, Weidner W, Zini A. Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair. Eur Urol. 2011. 60:796–808.

47. Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM. Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial. Eur Urol. 2011. 59:455–461.

48. Laven JS, Haans LC, Mali WP, te Velde ER, Wensing CJ, Eimers JM. Effects of varicocele treatment in adolescents: a randomized study. Fertil Steril. 1992. 58:756–762.

49. Al-Said S, Al-Naimi A, Al-Ansari A, Younis N, Shamsodini A, A-sadiq K, Shokeir AA. Varicocelectomy for male infertility: a comparative study of open, laparoscopic and microsurgical approaches. J Urol. 2008. 180:266–270.

50. Scherr D, Goldstein M. Comparison of bilateral versus unilateral varicocelectomy in men with palpable bilateral varicoceles. J Urol. 1999. 162:85–88.

51. Elbendary MA, Elbadry AM. Right subclinical varicocele: how to manage in infertile patients with clinical left varicocele? Fertil Steril. 2009. 92:2050–2053.

52. Zheng YQ, Gao X, Li ZJ, Yu YL, Zhang ZG, Li W. Efficacy of bilateral and left varicocelectomy in infertile men with left clinical and right subclinical varicoceles: a comparative study. Urology. 2009. 73:1236–1240.

53. Chen SS, Huang WJ, Chang LS, Wei YH. Attenuation of oxidative stress after varicocelectomy in subfertile patients with varicocele. J Urol. 2008. 179:639–642.

54. Smit M, Romijn JC, Wildhagen MF, Veldhoven JL, Weber RF, Dohle GR. Decreased sperm DNA fragmentation after surgical varicocelectomy is associated with increased pregnancy rate. J Urol. 2010. 183:270–274.

55. Zini A, Azhar R, Baazeem A, Gabriel MS. Effect of microsurgical varicocelectomy on human sperm chromatin and DNA integrity: a prospective trial. Int J Androl. 2011. 34:14–19.

56. Reichart M, Eltes F, Soffer Y, Zigenreich E, Yogev L, Bartoov B. Sperm ultramorphology as a pathophysiological indicator of spermatogenesis in males suffering from varicocele. Andrologia. 2000. 32:139–145.

57. Ichioka K, Nagahama K, Okubo K, Soda T, Ogawa O, Nishiyama H. Genetic polymorphisms in glutathione S-transferase T1 affect the surgical outcome of varicocelectomies in infertile patients. Asian J Androl. 2009. 11:333–341.

58. Nasr-Esfahani MH, Abasi H, Razavi S, Ashrafi S, Tavalaee M. Varicocelectomy: semen parameters and protamine deficiency. Int J Androl. 2009. 32:115–122.

59. Balci A, Karazincir S, Gorur S, Sumbas H, Egilmez E, Inandi T. Long-term effect of varicocele repair on intratesticular arterial resistance index. J Clin Ultrasound. 2008. 36:148–152.

60. Ozden C, Ozdal OL, Bulut S, Guzel O, Koyuncu HH, Memis A. Effect of varicocelectomy on serum inhibin B levels in infertile patients with varicocele. Scand J Urol Nephrol. 2008. 42:441–443.

61. Al-Kandari AM, Shabaan H, Ibrahim HM, Elshebiny YH, Shokeir AA. Comparison of outcomes of different varicocelectomy techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized clinical trial. Urology. 2007. 69:417–420.

62. Zucchi A, Mearini L, Mearini E, Fioretti F, Bini V, Porena M. Varicocele and fertility: relationship between testicular volume and seminal parameters before and after treatment. J Androl. 2006. 27:548–551.

63. Pasqualotto FF, Lucon AM, de Góes PM, Hallak J, Sobreiro B, Pasqualotto EB, Arap S. Testicular growth, sperm concentration, percent motility, and pregnancy outcome after varicocelectomy based on testicular histology. Fertil Steril. 2005. 83:362–366.

64. Barbalias GA, Liatsikos EN, Nikiforidis G, Siablis D. Treatment of varicocele for male infertility: a comparative study evaluating currently used approaches. Eur Urol. 1998. 34:393–398.

65. Matsuda T, Horii Y, Yoshida O. Should the testicular artery be preserved at varicocelectomy? J Urol. 1993. 149(5 Pt 2):1357–1360.

66. Sayfan J, Soffer Y, Orda R. Varicocele treatment: prospective randomized trial of 3 methods. J Urol. 1992. 148:1447–1449.

67. Yamamoto M, Hibi H, Katsuno S, Miyake K. Effects of varicocelectomy on testis volume and semen parameters in adolescents: a randomized prospective study. Nagoya J Med Sci. 1995. 58:127–132.

68. Mancini A, Milardi D, Conte G, Festa R, De Marinis L, Littarru GP. Seminal antioxidants in humans: preoperative and postoperative evaluation of coenzyme Q10 in varicocele patients. Horm Metab Res. 2005. 37:428–432.

69. Evers JL, Collins JA, Vandekerckhove P. Surgery or embolisation for varicocele in subfertile men. Cochrane Database Syst Rev. 2001. (1):CD000479.

70. Ficarra V, Cerruto MA, Liguori G, Mazzoni G, Minucci S, Tracia A, Gentile V. Treatment of varicocele in subfertile men: the Cochrane Review-a contrary opinion. Eur Urol. 2006. 49:258–263.

71. Marmar JL, Agarwal A, Prabakaran S, Agarwal R, Short RA, Benoff S, Thomas AJ Jr. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis. Fertil Steril. 2007. 88:639–648.

72. Madgar I, Weissenberg R, Lunenfeld B, Karasik A, Goldwasser B. Controlled trial of high spermatic vein ligation for varicocele in infertile men. Fertil Steril. 1995. 63:120–124.

73. Nieschlag E, Hertle L, Fischedick A, Abshagen K, Behre HM. Update on treatment of varicocele: counselling as effective as occlusion of the vena spermatica. Hum Reprod. 1998. 13:2147–2150.

74. Krause W, Müller HH, Schafer H, Weidner W. Does treatment of varicocele improve male fertility? results of the 'Deutsche Varikozelenstudie', a multicentre study of 14 collaborating centres. Andrologia. 2002. 34:164–171.

75. Kim ED, Leibman BB, Grinblat DM, Lipshultz LI. Varicocele repair improves semen parameters in azoospermic men with spermatogenic failure. J Urol. 1999. 162(3 Pt 1):737–740.

76. Matthews GJ, Matthews ED, Goldstein M. Induction of spermatogenesis and achievement of pregnancy after microsurgical varicocelectomy in men with azoospermia and severe oligoasthenospermia. Fertil Steril. 1998. 70:71–75.

77. Kadioglu A, Tefekli A, Cayan S, Kandirali E, Erdemir F, Tellaloglu S. Microsurgical inguinal varicocele repair in azoospermic men. Urology. 2001. 57:328–333.

78. Pasqualotto FF, Sobreiro BP, Hallak J, Pasqualotto EB, Lucon AM. Induction of spermatogenesis in azoospermic men after varicocelectomy repair: an update. Fertil Steril. 2006. 85:635–639.

79. Youssef T, Abd-Elaal E, Gaballah G, Elhanbly S, Eldosoky E. Varicocelectomy in men with nonobstructive azoospermia: is it beneficial? Int J Surg. 2009. 7:356–360.

80. Cayan S, Shavakhabov S, Kadioglu A. Treatment of palpable varicocele in infertile men: a meta-analysis to define the best technique. J Androl. 2009. 30:33–40.

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