Progressive Sperm Motility, Sperm Condensation and Spontaneous Pregnancy Rate in Infertile Varicocele Patients at 3-12 Months after Varicocelectomy
To evaluate the effect of varicocele repair on sperm motility, sperm condensation and pregnancy rate in varicocele patients who referred to Department of Urology of Golestan and Apadana hospitals. The records were retrospectively evaluated for infertile patients with palpable varicocele who underwent varicocelectomy at Department of Urology of Golestan and Apadana Hospitals, Ahwaz, Iran from December 1990 to September 2008. The semen analysis of patient at pre-operatives and 3, 6 and 12 months post-operative and also pregnancy rate was calculated at 3, 6 and 12 months of follow-up. Before operation, no significant differences were seen among patients with right and left varicocele in sperm motility and condensation (p>0.05). Significant differences were seen in sperm motility and condensation of patients with bilateral varicocele compared to another patients (p<0.05). After surgery in three groups of patients with varicocele, the sperm motility and condensation significantly increased (p<0.05). Percentage of spontaneous pregnancy in 1 year after varicocele treatment is 31 to 40% of cases. The results of present study have shown that repair of varicocele by surgery significantly improved sperm motility, condensation and also 31-40% of infertile patients achieved pregnancy spontaneously.
Varicocele is a dilation of internal spermatic veins that drain the testicle
(Kadyrov et al., 2007). It is very common condition
present in 15% of the general male population and 40% of men evaluated for infertility
(Naughton et al., 2001). A varicocele develops
because of defective valves that normally allow for blood to flow away from
the testicle toward the abdomen (Ahlberg et al.,
1996). Testicular injury occurs due to abnormal back flow of blood from
the abdomen into the scrotom and this create a hostile environment for sperm
development (Sepal et al., 1981). A unilateral
varicocele may affect both testicles (Jarow, 2001).
The most probable explanation for the more frequent development of a varicocele
on the left side alone is because the left spermatic vein is longer than the
right (Gray, 2005). The left vein enter the left renal
vein at a right angle near a site of compression by the mesenteric artery while
the right spermatic vein drains at a softer angle into the vena cava. These
anatomical factors promote back flow of blood in the left spermatic vein, resulting
in pooling of blood and increased temperature and congestion in the testicle
(Tam, 2004; Sigman and Jarow, 1997).
The diagnosis of varicocele can usually be made on physical examination of the
scrotom while the patient is standing. The varicocele feels like a bag of worms
and disappears or becomes significantly reduced when the patient lies down (Hargreave
et al., 1991). Repair of the varicocele is indicated when the couple
has documented infertility with normal or potentially normal female partner
but a male with one or more abnormal semen parameters and the presence of varicocele
on physical exam and also when a varicocele causes testicular pain or discomfort
or there is a significant discrepancy between the sizes of two testicles (Ishikawa
and Fujisawa, 2005). The important sperm functions are impaired in patients
with varicocele (El-Segini et al., 2002).
The improvement of seminal parameters after varicocele correction has been
reported by several investigators in clinical series (Libman
et al., 2006; Pasqualotto et al., 2005;
Gat et al., 2005; Grober
et al., 2004). Furthermore some researches suggest that varicocelectomy
can improve human sperm DNA integrity in infertile men with varicocele (Niederberger,
2005; Zini et al., 2005). Non randomized
comparative studies (Reichart et al., 2000;
Perimenis et al., 2001; Onozawa et al.,
2002) and randomized clinical trials (Madgar et al.,
1995; Nieschlag et al., 1988). More controversies
exist concerning the role of varicocele treatment to obtain pregnancy in infertile
couples (Evers et al., 2004; Ficarra
et al., 2006). The aim of this study was to evaluate the effect of
varicocelectomy on sperm motility, sperm condensation and pregnancy rate.
MATERIALS AND METHODS
This retrospective cross-sectional study included infertile patients with palpable
varicocele who underwent varicocelectomy at Department of Urology of Golestan
and Apadana Hospitals, Ahwaz, Iran from December 1990 to September 2008. This
study was reviewed and approved by the Institutional Ethics Committee of Ahwaz
Jondishapour University of Medical Sciences. All patients provided informed
consent. The Mean±SD patients age was 30.4±6.9 years (rang 16-40
years). Pre-operative evaluations included a complete history, physical examination
and semen analysis. The presence of varicocele was diagnosed on the basis of
venous diameter of greater than 3 mm, with increasing diameter during Valsalva
maneuvers or when changing from supine to upright with scrotal gray-scale ultrasonography
(McClure et al., 1991). Increased venous retrograde
flow in the pampiniform plexus in the upright position, or during the Valsalva
maneuver was used as a supporting sign of the presence of varicocele (Petros
et al., 1991). The varicocele diagnosis was assigned according to
World Health Organization (World Health Organization, 1993).
Varicocele was graded as:
||Grade I: A distinct dilation of the internal spermatic
veins palpable during a Valsalva maneuver when upright
||Grade II: A palpable vein when upright with no Valsalva maneuver
||Grade III: A vein both palpable and visible through the scrotal
skin when upright with no Valsalva maneuver
We excluded patient who were <16 or >40 years old, single patients, patients
with sub-clinical and grade one varicocele, patients with normal semen analysis
and patients with further pathologies that were associated to varicocele and
potentially were responsible for an alteration of semen analysis. In all patients,
pre-operative semen analysis were performed using two different semen specimens
(the higher value was adopted), each obtained by masturbation and at least 3
weeks pre-operatively and 3,6 and 12 months after varicocele treatment according
to the World Health Organization recommendation (1992a).
Specifically, the abstinence period was 2-3 days in all cases. Preoperative
evaluation included the execution of two semen analysis. The interval between
the two sample collections had to be >7 days or <3 weeks. The spontaneous
pregnancy rate was calculated at 3, 6 and 12 months after varicocelectomy.
Statistical analysis: The Chi-square and ANOVA were used as appreciated for comparisons sperm motility and sperm count before and after treatment of varicocele. The p-value less that 0.05 considered as significant difference. All computations were performed using the Statistical Package for the Social Sciences (SPSS-PC1for Windows; SPSS; Chicago, IL).
During this study the records of 1290 infertile men with varicocele who referred
to Urology Department of Golestan and Apadana hospitals in Ahwaz, Iran were
evaluated. The median age of patients was 30.4±6.9 years (rang 16-40
years). The varicocele was located on the right side in 144 (11.16%) cases,
on the left side in 1083 (83.95%) and bilaterally in 63 (4.88%). The median
value of the percentage of progressive motile sperm was 30.12, 28.83 and 19.53
in patient with varicocele located in right, left and bilateral side respectively
(Table 1). Statistical analysis show that the progress sperm
motility difference in patient with unilateral varicocele was not significant
(p>0.05) but difference between patient with bilaterally varicocele and patients
with unilateral varicocele was significant (p<0.05). Median sperm condensation
as 16.15, 13.63 and 9.52 in patient with varicocele located in right, left and
bilateral side, respectively. Statistical analysis show that sperm condensation
in patient with bilateral varicocele significantly low in compare with another
|| Progressive sperm motility in varicocele patients
|Data are expressed as Mean±SD
|| Sperm motility after 3-12 months after varicocelectomy
|Data are expressed as Median±SD
|| Sperm condensation 3-12 months after varicocelectomy
|Data are expressed as Mean±SD
The sperm condensation in two groups of patients with
varicocele in left and right was not difference (p>0.05).
As shown in Table 2 and 3; 39,105 and 11
patients were excluded from patients with right, left and bilateral varicocele
group, respectively. The remaining 105 (9.09%) patients with right side varicocele,
998 (86.04%) patient with left side varicocele and 52 (4.50%) patients with
bilateral varicocele met the study inclusion criteria.
The median value of the percentage of progressive motile sperm in patients
with right side varicocele was 45.11, 56.16 and 55.33, respectively in 3, 6
and 12 months after varicocelectomy. This data show that after varicocelectomy
the percentage of progressive motile sperm improved after repair of varicocele.
Significant differences were seen in 6 and 12 months compared to 3 months after
varicocelectomy (p<0.05). The difference between 6 and 12 months after surgery
was not significant (p>0.05). Sperm condensation in patients with right side
of varicocele at 3, 6 and 12 months after surgery was 20.75, 28.03 and 40.13
million mL-1, respectively and improved sperm concentration was seen
after surgery. The sperm condensation at 12 months after repair of varicocele
was significantly high (p<0.05). The median value of the percentage of progressive
motile sperm and sperm condensation in patients with left side varicocele significantly
improved after varicocelectomy and at 12 months after varicocelectomy were significantly
high (p<0.05) as same as in patient with bilateral varicocele highest sperm
motility and condensation achieved at 12 months after surgery.
In this study 17, 105 and 17 patients were excluded from patients with right,
left and bilateral varicocele group, respectively. The remaining 88 (9.60%)
patients with right side varicocele, 793 (86.57%) patient with left side varicocele
and 17 (3.82%) patients with bilateral varicocele met the study inclusion criteria.
||Percentage of spontaneous pregnancies 3-12 months after varicocelectomy
The fertilization rate in patient with varicocele at 3-12 months after repair
of surgery was 40.90, 40.85 and 31.42%, respectively (Table 4).
The difference between different type of varicocele was not significant (p>0.05).
Varicocele affects fertility and is the most common known cause of infertility
(Konodo et al., 2009). Various mechanisms have
been suggested to account for the testicular dysfunction associated with varicoceles,
including retrograde flow of toxic metabolites from the adrenal gland or kidney,
venous stasis with germinal epithelial hypoxia, alteration in the hypothalamic-pituitary-gonadal
axis and increases in testicular temperature (Takihara et
al., 1991 ). In addition, deregulations of nitric oxide (Miropoulos
et al., 1996), reactive oxygen species (Sharma
and Agarwal, 1996) and regulators of apoptosis (Fazilioglu
et al., 2008) have been implicated in the pathophysiology of varicoceles.
The results of the present study demonstrate that the repair of varicocele by
surgery cause highly significant improvement of progressive motility in sperm
and as same as condensation. Nasr-Esfahani et al.
(2009) in a study show that all the three semen parameters and percentage
of sperms with normal protamine content have improved post-surgery so that they
suggested that patients with low initial sperm count may benefit more from assisted
reproductive techniques or varicocelectomy followed by assisted reproduction.
The vast majority of physicians who manage male infertility patients believed
that varicoceles are a major cause of male infertility and that repair of varicocele
will improve fertility (World Health Organization, 1992b).
Some controversial researches are whether or not varicoceles should be repaired
prophylactically to prevent future infertility and whether varicocele size has
prognostic significance. Interestingly, the results of this research show that
the choice of varicocele to improve the fertility and pregnancy may be better.
The latter issue has a major impact upon deciding whether or not sub-clinical
(non-palpable) varicoceles should be diagnosed and repaired. However, there
are many clinicians who are not convinced that varicocele repair improves male
fertility (Kamischke and Nieschlag, 1999). Evers
et al. (2009) claimed that no evidence that treatment of varicoceles
in men from couples with otherwise unexplained subfertility improves the couples
chance of conception, interestingly the data of this study show that in patients
with varicocele 1 year after varicocele treatment, the percentage of spontaneous
pregnancies accounts for 31-40% of cases. This data is similar to earlier study
by Schlegel (1997). This study has documented reduced
sperm motility and condensation in men with bilateral varicoceles as compared
with unilateral varicocele men.
In conclusion based upon the current data available several conclusions maybe reached. First, there is very strong evidence to support the fact that, as observed for centuries, varicoceles exert a deleterious effect upon the sperm motility and condensation. This effect appears to be bilateral, even in men with unilateral Varicoceles. Second, repair of varicocele improved the sperm motility and condensation. Third, 31-40% of infertile patients one year after varicocele treatment achieved pregnancy. Finally, the varicocele surgery may be the correct choice to enhance the chance of the fertility and pregnancy.
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