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Hasan Farsi K.A. University Hospital King Faisal Specialist Hospital Jeddah
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 fructose FSH was normal. Bilateral inguinal varicocelectomy, testicular biopsy:
Hypospermatogenisis
one child
Varicocele
Ambrose Par (15001590): a clinical problem Barfield, late 19th century: Relationship to infertility Lipshultz, 1979: Relationship to testicular atrophy that is progressive with age Kass and Belman, 1987:significant increase in testicular volume after varicocele repair in adolescents
The mean follow-up duration was 76.2 months The pregnancy rate: (60%) VS (28%)
Int J Urol. 2002 Aug;9(8):455-61.
Surgery Vs Observation
146 men left varicocelectomy 62 men refused surgery treated with tamoxiphene Followed up for at least 1 year Improvement in semen parameters:
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 misclassification Of 136 studies identified through the electronic and hand search of references, only 17 studies met our inclusion criteria
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CONCLUSIONS: Surgical varicocelectomy significantly improves semen parameters in infertile men with palpable varicocele and abnormal semen parameters.
24 pts 63 intrauterine insemination cycles without varicocele treatment. 34 pts 101 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 = 0.04 Live birth rate per cycle =1.6 VS 11.8, p = 0.007
Conclusion: A functional factor not measured on routine semen analysis may affect pregnancy rates in this setting
68 infertile men Seminal plasma levels of two ROS and six antioxidants on the day prior to varicocelectomy Same parameters were measured again 3 and 6 months postoperatively. 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. 2001 Oct;24(5):261-5.
286 infertile men Physical examination, contact thermography, Doppler sonography, and venography of both testes. 88.8% bilateral Mean sperm concentration increased from 6.12 +/- 1.02 to 21.3 +/1.69 million/mL mean sperm motility from 16.81 +/- 1.51 to 35.90 +/- 1.41% mean sperm morphology from 9.75 +/- 0.85 to 16.92 +/- 1.17%. Pregnancy rate was 43.5%
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 $89,091 The cost per delivery after varicocelectomy was only $26,268 The 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 varicoceleassociated male factor infertility with surgical varicocelectomy is more cost-effective than primary treatment with assisted reproduction.
4.3-13.3%
Interestingly, the first study on the importance of varicocelectomy to male infertility (Tulloch, 1952 ) reported spontaneous pregnancy after varicocele repair in an azoospermic man
Results of ligation of internal spermatic vein in the treatment of infertility in azoospermic patients.
13 azo inguinal varicocelectomy Induction of spermatogenesis was achieved in 3 (23%) patients Two of them had hypospermatogenesis and one had maturation arrest at spermatid stage No pregnancies by natural intercourse
14 Azo sclerotherapy 7/14 produced sperms Sperm con 3.1 1.2 106/mL Mean sperm: 2.2 1.9% mean sperm normal morphology: 7.8 2.2% 2 pregnancies
Embolization of Varicocele
sperm concentration in the ejaculate 3.811.69 x 106/ml mean sperm motility: 1.203.62% mean sperm morphology: 8.302.64 Four (12%) unassisted Five (15%) by ICSI
17 azo microsur Spermatozoa in the ejacultae 47% (8/17) Only 35% (6/17) of them had motile sperm Mean time for appearance of spermatozoa in the ejaculates was 5 months (3 to 9 months).
Predictors of Success
Response to varicocelectomy in oligospermic men with and without defined genetic infertility.
26 No defect
Same semen parameters All had varicocelectomy 54% VS 0% improvement CONCLUSIONS: 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.
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:
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.
FSH
Histology
FSH
Preoperative 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 different
Czplick M. Arch Androl. 1979;3(1):51-5
Histology
Germinal Aplasia Maturation arrest at spermatocyte stage Hypospermatogenisis Maturation arrest at spermatid stage
13 Azoospermic patients
No association
No. of pts 33 22 24 28 31
Cakan
Pasqualotto Lee Esteves Gat Poulakis Osmonov
2004
2006 2007 2005 2005 2006 2006
13
27 19 17 32 14 15
Inguin
Micro Micro Micro Embo. Sclero sclerot
3(23%)
9(33.3) 7(36.4%) 8(47%) 18(56.2%) 7(50) 8(53) all <0.1m/cc
Nil
1 1 1 Spontan 4 ICSI 9(26%) 2 Nil
TOTAL
275
108 (39.27%)
Subclinical Varicocele
subclinical in 73 patients Clinical 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.
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 varicocele Conclusion: The results of our study suggest that subclinical varicocelectomy is of questionable benefit.
Fertilization and pregnancy rates after intracytoplasmic sperm injection using ejaculate semen and surgically retrieved sperm.
350 patients:
CONCLUSION: 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.
Conclusion
Varicocele 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