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OBJECTIVES: To perform a historicalreview of varicocele and male infertility with the aim tofind descriptions that first related them. In parallel, wereview the evolution of treatment for varicocele up todate.METHODS/RESULTS: We refer to multiple authors andtheir treaties on Medicine, from first to 20th Century, inwhich descriptions of these pathologies are found, focusingon descriptions of the surgical technique for treatment ofvaricocele and their application in Spain.CONCLUSIONS: Varicocele was already described intreaties from the first century, having bee of n its treatmentpredominantly surgical from the first description to ourdays. Not identified as a cause of infertility until late,by the end of the 19th century, it is the main indicationfor treatment nowadays. The surgical technique hassuffered many modifications over time, both in theapproach as in the “radicality” of a vascular ligatureapplied.to predominantemente quirúrgico desde su primeradescripción hasta nuestros tiempos. Su identificacióncomo causa de infertilidad fue tardía, finales siglo XIX,siendo ésta la principal indicación de tratamiento en laactualidad. La técnica quirúrgica empleada ha sufridomúltiples modificaciones a lo largo de los tiempos,tanto en la vía de abordaje como en la “radicalidad”de la ligadura vascular applied.
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OBJECTIVES: To review current theoriesabout etiology of varicocele and pathogenic mechanismsleading to a progressive disorder of spermatogenesis inrelation to the subfertility or infertility these patients maypresent with. To evaluate its current anatomicalknowledge of the normal venous drain of the testicleand its variations that may condition relapse or failureof the treatment of varicocele. To systematically reviewpathologic testicular lesions in patients with varicocele.To establish factors that may have prognostic significaceon post-treatment fertility.METHODS: We performed a systematic search in theMedline database for each of the proposed etiologicaland pathogenic theories on human varicocele. Theevaluation of pathologic testicular lesions in patientswith varicocele was obtained from the study of testicularbiopsies performed at the Hospital La Paz in Madridover the last 30 years.RESULTS: Regarding the anatomical theories of varicocele,congenital absence or incompetence of the internalspermatic vein valves, difficult venous drain, augmentedhydrostatic pressure of the internal spermatic vein, disorderof the fascial-muscular pump mechanism, and compressionof the venous drainage system are considered, amongothers, potential etiological factors.Regarding possible pathogenic theories of varicocele,we evaluate disorders of testicular thermoregulation,hypoxia, toxic effect of renal and adrenal metabolites,certain endocrine disorders, obstruction of the spermatictract, disorders of blood flow and epididymal vasculature,oxidative stress, gonadotoxins, apoptosis, and lastly theeffect of varicocele on the contralateral testicle.CONCLUSIONS: Available data support the idea thatetiopathogenesis of varicocele is multifactorial. Many classic etiopathogenic factors related to anatomy,embryology, obstruction, and hyperthermia still prevailin addition to new factors related to oxygen reactivespecies and apoptosis. However, many pathogenicand physiopathologic aspects of varicocele need to beelucidated yet. As a matter of fact, neither of these dataalone may clearly explain the variable effect varicocelehas on spermatogenesis and male fertility. So, it isnecessary to establish histological criteria with provedprognostic significance that allow us to detect possibleprogression of testicular lesions after treatment.
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OBJECTIVES: To review the ultrasound technique, normal anatomy, bibliography, as well as the most frequent scrotal ultrasound findings in infertile patients studied in our center over the last five years, with special emphasis in the diagnosis of varicocele and its follow-up after surgical treatment or embolization. METHODS: We reviewed a total of 439 male patients with the diagnosis of infertility referred to our vascular ultrasound section between 1998 and 2004, and 101 patients referred for ultrasound control after treatment of varicocele (endovascular or surgical). RESULTS: The most frequent diagnosis associated with infertility were left varicocele (146 patients, 33.3%), right varicocele (39 patients, 8.9%) and intratesticular varicocele (1 patient, 0.2%). Only one patient had a right-side-only varicocele (0.2%), the rest of the cases of right varicocele having bilateral affectation (38 patients, 8.7%). Other relevant diagnoses found were testicular atrophy, epididymal lesions, microlithiasis, inguinal scrotal hernias, testicular tumors, and dilation of the rete testis. CONCLUSIONS: Testicular ultrasound should be performed in every patient with unexplained infertility and abnormal sperm analysis. It allows diagnosis of more pathologic conditions than physical examination. Besides a rapid varicocele screening, colour Doppler ultrasound allows us to evaluate its hemodynamic repercussion, by studying the spectral display, colour and response to Valsalva’s. It also provides an exact measure of testicular volume, allows to detect the presence of dystrophic changes in the testicle, as well as anomalies of the epididymis and vas deferens, such as cystic dilations. It is also the test of choice to detect non descended testicles. Ultrasound may also detect non palpable testicular tumors which are more prevalent in this group of patients.
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OBJECTIVES: To compare the concentra-tion of leukocytes and round cells in semen samples of subfertile males(SM), men with varicocele(VM), and fertile males(FM) to establish a possible relationship between leukocyte concentration, semen parameters (pH, concentration, mobility, spermatic morphology) and lipidic peroxidation of the spermatozoid. METHODS: We evaluated 298 semen samples from: 42 fertile males, 170 subfertile males, and 86 men with varicocele. Sperm tests were performed following WHO criteria. All samples with leukocyte counts higher than 1 million/ml were submitted for oxidative stressstudy (malonyldialdehyde in seminal plasma).RESULTS: Leukocyte concentration was higher in subfertile males and men with varicocele (2.5+- 2.1 x 10 6 /ml and 2.3 +-2.1x106/ml) than in fertile males (1.1+-0.1x 10 6/ml) (p 0.0001). In the same way concen-tration of round cells was higher in the SM group (6.5+-0.3x 10 6/ml) and VM group (6.1+- 0.4x 10 6/ml) than in FM (4.5+- 0.4x 10 6/ml) (p 0.05).Spermatozoid concentration was lower in SM (42.1+-2.4x106/ml) and VM (9,9+-3,5x106/ml) than in FM (82.4+- 5.7x 10 6/ml) (p 0.0001). The percentage of spermatozoa with type “a” mobility was lower in the SM (14.1+- 0.9) and VM (19.9+- 1.4) groups than in the FM group (50.0+- 1.3) (p 0.0001). In the same way, “a +b” mobility was lower in the SF group (26.7+-1.4) and VM group (34.1+- 1.9) than in the FM group (50.0+- 1.3) (p 0.0001). The SM group showed alower percentage of normal forms (43.3+- 1.5) than the VM (50.0+- 1.6) and FM (60.6+- 1.3) groups (p0.0001). When grouping by concentration of peroxidase positive cells, there were not statistical differences in the spermatic variables in SM, with the exception of progeny cells. Type “a” mobility in the VM group was lower in the peroxidase positive group than in the peroxidase negative group (p 0.005); “a+b” mobility was also lower in the peroxidase positive men than in peroxidase negative (p 0.01); in the progeny cells they were higher in the peroxidase positive males (4.2+-0.4x 10 6/ml) than in peroxidase negative males(3.0+- 0.3 x 10 6/ml). Malonyldialdehyde concentrations were significantly higher in seminal plasma of subfertile and varicocele males than in fertile males (p 0.006, and p 0.03).CONCLUSIONS: Increased number of semenlymphocytes is more frequent in subfertile and varicocele males than in fertile males. The increase of semen leukocytes is associated with deterioration of seminal parameters. Oxidative stress has a negative influence on seminal parameters in subfertile males of unknown etiology.
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We performed an extensive bibliographicsearch, and review the alternatives for surgical treatmentof varicocele, especially microsurgical techniques.The surgical techniques for varicocele have not sufferedmuch variation over the last years, being their usegeneralized among urologists. The lower incidence ofrelapse and secondary hydrocele to lymphatic lesionmake retroperitoneal techniques be used less frequentlyin favour of inguinal or subinguinal techniques,microsurgical or not.For better understanding of the surgical indications anddevelopment of techniques we offer some short anatomicaland physiopathological comments about varicocele.
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OBJECTIVES: To report our experienceon percutaneous treatment of male varicocele over thelast 15 years.METHODS: 690 patients with left varicocele underwentpercutaneous occlusion of the spermatic vein.Embolization was undertaken using various types ofmaterials; the most frequently used association was coilsand sclerosing substances.Thorough clinical control was carried out, includingultrasound and spermiogram when indicated.RESULTS: Initial success rate was 97.8% and complicationrate was 6.2%. Varicocele persistence or relapse wasfound in 13.2% of the cases after embolization.In the group of patients with sperm tests on follow-up,sperm counts became normal in 46% of the patients,and “a + b” mobility in 35%. Post-treatment pregnancyrate was 20%.CONCLUSIONS: Percutaneous occlusion of the spermaticvein is a very extensively developed technique. Itsefficacy and nearly null rate of severe complications,associated with its good results, make it the techniqueof choice in the treatment of male varicocele.
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Summary.- OBJECTIVES: Varicocele is a dilation ofthe pampiniform venous plexus in the spermatic cord. Itappears in 15% approximately of general populationmales. It is the most commonly identifiable, surgicallytreatable lesion associated with male infertility. The surgicaltreatment of varicocele, either unilateral or bilateral, hasdemonstrated a significant improvement in seminalparameters at least in two-thirds of affected males, and30% to 60% pregnancy rates.There are many controversies about the indication ofsurgical treatment, more popular than percutaneousembolization, because several series have not demonstratedclear benefit; nevertheless, most authors support surgery,because its low morbidity, it is easy to perform, has arapid adaptation process, and improves seminalparameters in most cases, or at least prevents theirprogressive impairment observed when surgery is notperformed.
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OBJECTIVES: Current trends in the treatmentof varicocele are focused on outpatient procedures ofhigh and complete ligature of the spermatic vascularpedicle or percutaneous embolization.Laparoscopic varicocelectomy competes with them andother minimally invasive techniques such as chemical orthermal sclerosing therapy of the spermatic veins.METHODS: We perform a bibliographic review of theSpanish and Anglo-Saxon literature with the aim ofevaluating the real weight of the laparoscopic technique,and at the same time show our personal experience.RESULTS: We found 8 papers in Spanish and 187 inEnglish. Although the interest for laparoscopicvaricocelectomy among Spanish urologists is very low,in other countries there is moderate interest for it, beingin competition, though in disadvantage, with other out-patient minimally invasive techniques performed underlocal or regional anesthesia.CONCLUSIONS: Microlaparoscopy improves theoverall position of this technique, mainly in cases ofbilateral varicocele whenever an “en bloc” ligature ofthe spermatic artery and vein is performed
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OBJECTIVES: To evaluate the effect of interventionist treatment of varicocele, either open surgery or endovascular radiological occlusion, on seminal parameters, and to identify which factors are associated with their normalization. METHODS: Between 1975 and 2000, 631 patients with the diagnosis of idiopathic varicocele were evaluated in our hospital; 238 of them were part of an infertile couple. Among them, finally, 183 underwent studies; they complied with the following criteria: 1) Infertility for more than one year; 2) seminal parameters below normality following WHO criteria (1992); 3) absence of other pathologies or diseases which could explain male infertility; and 4) absence of evident causes of male infertility. 131 patients were treated by radiological occlusion and 26 by conventional surgery. The remaining 26 patients did not undergo the treatment indicated. Two parameters were evaluated on follow-up: 1) achievement of pregnancy (these results will be analyzed in a next article), and 2) normalization of seminal parameters. RESULTS: 48% and 39% of the patients respectively achieved normalization of the number of spermatozoids per ml (=20 million spermatozoids per ml) and spermatic morbidity (=50%). The association between normalization of seminal parameters and age, clinical grade, or type of treatment was not demonstrated. Only baseline degree of severity in the alteration of seminal parameters showed statistically significant differences in the evaluation of semen quality after treatment of varicocele (p = 0.001 and p = 0.002). CONCLUSIONS: The degree of previous seminal alteration — oligospermia and asthenospermia— was the factor with greatest prognostic value in relation with normalization of seminal parameters.
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OBJECTIVES: To analyze the efficacy ofvaricocele treatment, either surgical or endovascularradiological occlusion, on pregnancy rates of infertilecouples in which the male had clinically patent leftvaricocele, and to identify which factors are associatedwith the probability of obtaining pregnancy in suchcases.METHODS: This study is part of a more ample onedescribed in previous article: “The treatment of varicocelein the infertile male I: Results on semen quality”. Overall,183 couples were included. 157 males receivedtreatment (131 radiological occlusion and 26 open surgery),the remaining 26 did not received the treatment indicated.Couples underwent periodic follow-up during the firstyear, evaluating two parameters: 1) normalization ofsemen analysis parameters, and 2) pregnancy duringthe following 12 months after indication of treatment.RESULTS: Overall, 41 couples (22.4%) achievedpregnancy during first year, 35/157 (22%) in thegroup of treated patients, and 6/26 (23%) in the nontreatment group. In the treatment group, surgical ligatureachieved higher pregnancy rates than radiologicalocclusion (35% vs. 20%), but the difference was notstatistically significant (p = 0.255). No associationwas demonstrated between male age, female age,varicocele clinical grade, degree of semen qualityabnormalities, or duration of infertility and pregnancyrates. The FSH value was significantly lower (p 0.0006)in patients who achieved pregnancy.CONCLUSIONS: The degree of semen qualityabnormality, which so closely correlated to normalizationof seminal parameters, lacked of prognostic significancein terms of achievement of pregnancy. The FSH valuewas the only factor with certain prognostic value,although it did not reach significance in logistic regressionanalysis.
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OBJECTIVES: The management ofvaricocele in the adolescent continues to be undercontroversy. Due to its high prevalence some authorssupport treatment in selected cases only. However,histological changes secondary to its presence havebeen demonstrated.The objective of this article is to analyze the efficacy,safety, and side effects of spermatic vein ligature byPalomo’s technique in adolescents, and to evaluatesemen parameters on the long-term.METHODS: Study population: adolescents with diagnosisof varicocele, grades II and III, confirmed by ultrasoundwho underwent surgery by the Palomo’s technique.Data analysis: In patients over the age of 18 willing toparticipate, semen parameters were studied in 1 or 2samples depending on results of the first analysis.RESULTS: From 1990, 266 adolescents with the diagnosisof grade II and III varicocele with a mean age of 15years underwent surgical ligature of the spermatic veinfollowing the technique described by Palomo. Sixpatients (2.2%) have had varicocele persistence. As amain complication, 23 (8.6%) of them developed lefthydrocele requiring surgery. We found no case oftesticular atrophy. Twenty-nine patients were availablefor post operative semen analysis (=19 years of age)obtaining the following mean values: semen volume:3.8 cc; overall spermatozoid count: 127 x 10 6;spermatozoa concentration per cc: 37 x 106; mobility(grade II+III): 56.6%; morphologically normalspermatozoa: 17%.CONCLUSIONS: Surgical ligature of the spermaticvein by the Palomo’s technique is fast, easy, effective,and has scarce side effects.Semen analysis parameters mainly show secondarysubfertility or teratozoospermia. We believe that if thereis a time for the treatment of asymptomatic varicocelethat is puberty.
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OBJECTIVES: Surgery has been largely indicated for varicocele with the aim of improving semen parameters in male patients with subfertility or infertility. However, the criteria for therapeutic success in which its usefulness has been based on have never been clear. Our objective was to analyze current criteria for therapeutic success after surgical treatment of varicocele, studying in depth the possible influence of varicocele on semen quality, its impact on fertility, and possible advantages of treatment. METHODS: We reviewed a group of original articles, systematic reviews, and metanalysis on the issue after MEDLINE search. We mainly focus on randomized placebo-controlled prospective studies the aim of which was to evaluate the improvement in semen quality and/or pregnancy rates in subfertile/infertile couples after treatment of varicocele. CONCLUSIONS: There is great study heterogeneity, both in methods and possible interpretation of results. Although it seems treatment of varicocele may improve some semen quality parameters, it does not seem to represent an effective treatment for male subfertility.
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OBJECTIVES: We review the main issueson epididymis obstruction and its diagnosis, as well astherapeutic indications and surgical techniques forepididymovasostomy.METHODS: We describe the microsurgical end-to-sideepididymovasostomy technique using double needle10-0 sutures.RESULTS: Various techniques of epididymovasostomyachieve seminal tract permeability in 39-86% of thecases and pregnancy in 13-42%.CONCLUSIONS: Microsurgical epididymovasostomyand testicular/epididymal spermatozoid recovery forICSI are the alternatives for epididymal obstruction. Thechoice of the most adequate method depends onvarious factors and patient`s preferences after properinformation.
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OBJECTIVES: Oncological therapies,either surgery, radiotherapy or chemotherapy, maycause irreversible subfertility/infertility. Both chemotherapyand radiotherapy have cytotoxic effects on gametogenesisand there are not preventive alternatives currently available.The objective of this article is to review current criteriafor semen cryopreservation and its usefulness as amethod for preservation of fertility in patients with cancer.METHODS/RESULTS: We reviewed a large group ofrecent original articles and systematic reviews on theissue with a common feature: evaluation of fertility statusafter oncological therapy.CONCLUSIONS: Every male patient in fertile age whocould wish future fatherhood should be offered theoption to storage cryopreserved semen samples beforestarting oncological therapies, with the exception ofpatients with azoospermia at the time of diagnosis.
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OBJECTIVES: Since first pregnancy afterICSI was achieved in 1992, the treatment and prognosisof severe male factor, i.e azoospermia, has radicallychanged. The objective of this article is to review theissue from the urologist-andrologist point of view.METHODS: We perform a short revision of the twotypes of azoospermia and diagnostic tests, and showthe algorithm used in our centre for the management ofpatients with azoospermia.We review the techniques for spermatozoid recoveryand surgical treatment of obstructive azoospermia because the role of the urologist is maximum in theseaspects.Genetic anomalies in azoospermic patients is one of theissues analyzed in more detail for being one of the mostimportant and of maximum interest currently.RESULTS: Nearly 1% of pregnancies in developed countriesare achieved by assisted reproduction techniques, andgenetic anomalies among newborns from ICSI cycleshave increased to 1.6%, three times normal population.Genetic anomalies are tenfold in azoospermic patientsin comparison to general population. We analyze theimportance of these studies in patients with secretoryazoospermia. We review the most frequent geneticanomalies associated with azoospermia and diagnostictests employed. Its importance is based on this diagnosisallowing genetic counselling and pre-implant or prenataldiagnosis with the aim of trying to minimize geneticanomalies and disease transmission to next generations.CONCLUSIONS: The diagnosis and treatment ofazoospermia continues to be one of the most thrillingchallenges in the field of infertility, with promising researchlines such as in vitro spermatogenesis from stem cellsand autotransplantation of criopreserved cells inpatients undergoing radiotherapy and chemotherapy.
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The introduction of intracytoplasmicspermatozoid injection (ICSI) not only has improvedsignificantly the prospects of fertility after assistedreproduction by using spermatozoa recovered from the seminal tract, but also has allowed extension of thespectrum of recovery techniques. For obstructive azoospermia,it is currently possible to use not only spermatozoaobtained by microsurgical techniques from the epididymis(MESA), but also spermatozoa obtained from the testicleby means of testicular biopsy (TESE), or spermatozoapercutaneously aspirated from the testicle/epididymis byminimally invasive techniques (TESA, PESA). Minimalrequirements in terms of spermatic quality for ICSI havealso allowed to successfully criopreserve epididymaland testicular spermatozoa. ICSI results are notinfluenced by the origin of spermatozoa (epididymis ortesticle), neither by the technique of spermatic recovery.Fresh or criopreserved spermatozoa microinjections arenot different either.On the other side, 40-60% of patients with secretoryazoospermia show small foci with preservedspermatogenesis in their testicles. For ICSI, these scarcespermatozoids may also be extracted from the testicleby multiple open biopsies, percutaneous aspiration, ormicrosurgical biopsies (micro-TESE). Nevertheless, insecretory azoospermia the yield of percutaneoustechniques is lower than open or microsurgical procedures.It is also possible to criopreserve testicular spermatozoa insecretory azoospermia without the process significantlyinfluencing ICSI results.Finally, spermatozoid testicular recovery by biopsy orpercutaneous aspiration followed by ICSI has also beenemployed as a resource in patients with necrozoospermiaand anejaculation.
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The development of fertilization techniquessuch as ICSI, complementary to conventional in vitrofertilization, have been a great advance in the treatmentof the male factor. ICSI with spermatozoa from ejaculateallows successful treatment of severe male factor,patients with previous failures of fertilization, and alsocases without apparent cause. ICSI with spermatozoaobtained directly from the testicle allows couples inwhich the male suffers azoospermia , either obstructiveor secretory, achieving pregnancy. After ICSI, pregnancyrates are similar to the ones after conventional in vitrofertilization. It is necessary to evaluate the genetic riskfor children born after ICSI. On the one hand there areanomalies bound to subfertile population they comefrom, on the other chromosome anomalies generatedde novo. ICSI does not increase the incidence of majormalformations. It is recommendable to perform prenataldiagnosis in pregnancies obtained by ICSI.
