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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 6  |  Page : 1100-1105
Complications and the effect of varicocelectomy on semen analysis, fertility, early ejaculation and spontaneous abortion


Department of Urology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran

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Date of Web Publication4-Nov-2010
 

   Abstract 

Varicocele is still an enigma. Its effects on semen analysis, fertility and, more re­cently, early ejaculation and spontaneous abortion in spouses are not yet fully understood. In this retrospective study, we evaluated these four parameters (semen analysis, fertility, early ejacu­lation and spontaneous abortion among spouses) in relation to varicocele and varicocelectomy during a 13-year period. A total of 1,711 patients with varicocele underwent varicocelectomy by high inguinal method (251 cases), subinguinal method (1,375 cases), scrotal method (34 cases), and subinguinal method with local anesthesia (38 cases). Our complication rate was acceptable. Sperm count, motility and morphology increased three months post operation in 55, 51, and 46%, respectively (P value 0.000, 0.000, and 0.015, respectively). Paternity was 56% after one year of post varicocelectomy follow-up. Only 7 out of 82 azoospermic men had sperm in their semen after varicocelectomy and only one of them with mild spermatogenic hypoplasia became a father. The spontaneous abortion rate in the spouses of respondents was 59%. Early ejaculation improved in 75% of the respondents. In conclusion, varicocelectomy does not improve sperm parameters in all men, but it improves pregnancy rate, early ejaculation, and scrotal pain.

How to cite this article:
Shamsa A, Nademi M, Aqaee M, Fard A N, Molaei M. Complications and the effect of varicocelectomy on semen analysis, fertility, early ejaculation and spontaneous abortion. Saudi J Kidney Dis Transpl 2010;21:1100-5

How to cite this URL:
Shamsa A, Nademi M, Aqaee M, Fard A N, Molaei M. Complications and the effect of varicocelectomy on semen analysis, fertility, early ejaculation and spontaneous abortion. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Sep 21];21:1100-5. Available from: http://www.sjkdt.org/text.asp?2010/21/6/1100/72298

   Introduction Top


Varicocele and its associated complications are still an enigma. Its effect on semen ana­lysis and fertility is a matter of debate. [1] Vari­cocele is also considered to be responsible for early ejaculation and spontaneous abortion although this has not been proven definitely. [1],[2],[3],[4],[5] In this retrospective interventional study of patients having varicocele and undergoing va­ricocelectomy during a 13-year period, with patients as self-control, we evaluated four para­meters (semen analysis, fertility, early ejacula­tion and spontaneous abortion among spouses) and their relation to varicocele.


   Subjects and Methods: Top


From 21 March 1990 till 20 March 2003, 1,711 patients with varicocele were admitted. We filled out a form providing the patient's age, marital status, chief complaints, other com­plaints, original and concomitant diseases, side and grade of varicocele, type of procedures and their complications (if any), semen analysis before the operation and three months after the operation, testicular biopsy (as needed), pater­nity after operation, early ejaculation (from 22 September 1997; among 872 patients) and spon­taneous abortion (among the spouses of 117 patients). We analyzed these data with SPSS software, using paired samples t test and chi­square. Procedure of varicocelectomy methods were retroperitoneal, scrotal (both stopped), sub inguinal (with general anaesthesia), sub ingui­nal (with local anaesthesia), and laparoscopic varicocelectomy.

During this period 1,711 patients underwent varicocelectomy because of infertility (91.7%), testicular pain (48%), the heavy sensation of varicocele, and a stress pattern in the semen analysis [Table 5]. For evaluating the effect of varicocelectomy on semen analysis, we exclu­ded patients with concomitant diseases, e.g. vas agenesis, history of orchitis, history of cryptorchidism, etc., which may have effect on semen analysis (1,683 patients remained).

We also had 84 patients with infertility, vari­cocele, and azoospermia.

For spermatic vein ligation, we predominantly used 2-0 chromic catgut rather than silk.


   Results Top


The mean age of 1,711 varicocelectomy pa­tients was 27.87 ± 6.5 years (range: 11-66 years) and the mean follow-up period was 8.75 ± 13.9 months. Majority of the varicoceles were on the right side (63.1%) and was bilateral in 25% and 76.1% were of grade II documented in 264 patients only.

Inguinal hernia was present in 74 cases (4%), and 1,242 out of 1,711 patients had male infer­tility.

Also, 140 out of 1,242 infertile men underwent testicular biopsy. The results were: normal (8), spermatogenic hypoplasia (78), incomplete sper­matogenic maturation arrest (16), complete sper­matogenic maturation arrest (17), and germinal aplasia (21).

Seven infertile men with azoospermia and va­ricocele underwent bilateral testicular biopsy and chromosomal study. The summary of the results is shown in [Table 1].
Table 1 :Evaluation of azoospermic men, including chromosomal study.

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Paternity after varicocelectomy differed ac­cording to the follow-up period [Table 2].
Table 2 :Fertility according to follow up period.

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82 out of 84 infertile and azoospermic male patients underwent varicocelectomy. Their ages were between 22 - 60 (mean 30.7 ± 7.2) years. 80 (95.2%) had primary infertility and 4 (4.8%) had secondary infertility.

The results of testicular biopsy were as follows: normal (6), spermatogenic hypoplasia (18), in­complete spermatogenic maturation arrest (4), complete spermatogenic maturation arrest (14), germinal aplasia (18), and undetermined (24).

The results of varicocelectomy in azoosper­mic patients were as follows.

Only one patient with normal spermatoge­nesis, and 9 out of 32 azoospermic patients with germinal aplasia and complete spermato­genic maturation arrest at three months post-op were still azoospermic.

One out of four azoospermic patients with in­complete spermatogenic arrest had a sperm count of around one million/mL and another azoospermic patient with moderate spermatoge­nic hypoplasia had a sperm count of 500,000/ mL at three months of follow-up post-op.

The spouse of one azoospermic patient with mild spermatogenic hypoplasia in the testicu­lar biopsy became pregnant.

Four azoospermic patients with severe sper­matogenic hypoplasia achieved spermatogene­sis as shown in [Table 3].
Table 3 :Spermatogenesis post varicocelectomy in four azoospermic men.

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Complications of the surgical procedure are shown in [Table 4]. Hydrocele occurred more co­mmonly after retroperitoneal approach (P = 0.02).

However, there was no significant difference between the two main surgical approaches in the recurrence or persistence of varicocele (P = 0.2)

Patients' complaints with varicocele are shown in [Table 4] and [Table 5].
Table 4 :Complications according to the type of surgery.

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Table 5 :Signs and symptoms of varicocele.

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97% of patients had decrease in the pain sensation among the 219 cases responding.

The effect of varicocelectomy on semen ana­lysis at three months follow-up is given in [Table 6].
Table 6 :Sperm count before and after varicocelectomy.

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Among 117 patients with varicocele, sponta­neous abortion was reported among 69 (59%) of the spouses (P < 0.05).

Also, 499 (58%) out of 862 varicocele pa­tients had early ejaculation. The incidence of early ejaculation in our population was 27% (P = 0.000). [4] Three months post-op, 206 out of 499 patients were asked about any improve­ment of early ejaculation and majority; 154 (75%) patients reported improvement.


   Discussion Top


Most of the references stated the incidence of clinical spontaneous abortions as 15%. [2] How­ever, in a survey which was conducted in Iran, this number was 7.15%. [3] Varicocele is a trea­table cause of male infertility, with a high pre­valence of 15% of normal males and 40% of the infertile male population. [5]

It has been mentioned since ancient times [6] with surgical management performed by Albu­casis of Cordova (Abu al-Qasim Khalaf ibn Abbas al-Zahravi: 930-1013 AD). [7]

During a 13-year period (from 21 March 1990 to 20 March 2003), we operated on 1,711 patients with varicocele.

Physical examination during erect and decu­bitus positions is the key for varicocele diag­nosis. However, we confirmed the diagnosis by standard scrotal sonography and sometimes color Doppler sonography, especially for the detection of subclinical varicocele. Other mo­dalities such as venography and contact ther­mography are thought to be more accurate and complimentary to physical examination and ul­trasonography. [8] The majority of our patients un­derwent varicocelectomy for infertility (91.7%) and pain (48%) [Table 5]. Lot of controversy exists about varicocele and its effect on preg­nancy. [9]

It is now believed that varicocele develops from absent or incomplete valves in the internal spermatic vein, accompanied by a retrograde blood flow down this vein and the cremastric vein to the pampiniform plexus. This pheno­menon leads to on increase of 2.5ºC of the scrotal temperature and several other changes, i.e. loss of spermatocyte and spermatid. [10] How­ever, increased cadmium, even in unilateral varicocele, can accumulate bilaterally and then induce apoptosis and decrease sperm concen­tration. [11]

Diamond et al [12] believe that varicocele is not a progressive disease but others, [13] as documen­ted in our data, have shown it to be a progre­ssive disease. 73 subjects in our study had se­condary infertility. Tolluch in 1955 reported an azoospermic male with bilateral varicocele, who became fertile after varicocelectomy and had two children. Afterwards, however, he un­derwent a vasectomy. [14]

Our data show improvement in sperm count, motility and morphology similar to other stu­dies. [15],[16]

The ultimate goal of varicocele repair is preg­nancy of the spouse.

The pregnancy rate after varicocelectomy in­creases partly because of the increased quan­tity and quality of sperm, and partly because of the decrease in the defects of sperm heads or change in the milieu of sperm (e.g. decrease in cadmium). [16] The range of pregnancy after va­ricocelectomy varied from 20 to 50% in the li­terature. [17],[18] Paternity among our patients was 56%, one year after their operations.

The effect of varicocelectomy on pregnancy remains controversial in different studies. [15],[16],[17],[18],[19] Similarly, the grade of varicocele and its effect on semen analysis is controversial. [15],[20],[21]

Varicocelectomy is advocated in azoospermic men with normal sized testis and palpable va­ricocele [22],[23],[24] since successful paternity is co­mmon after varicocelectomy. We could not get the information from all our patients with in­fertility and a single case among 82 azoo-spermic men reported successful paternity. Cryo­preservation of semen is therefore suggested for viable sperms. [25]

It is interesting to note that seven of our pa­tients had abnormal karyotype among azoo­spermic patients with varicocele and abnormal spermatogenesis. Earlier, Pryor et al reported 2 out of 71 cases of varicocele with Y chromo­somal deletions. [25]

When artificial reproductive technology is available it is recommended in patients with varicocele to undergo varicocelectomy for bet­ter results and likelihood of successful preg­nancy post operatively. [26],[27]

Our surgical approach had similar results al­though majority of our patients underwent sub­inguinal approach without the use of micros­cope, as reported by others. [28]

The limitations of our study include lack of proper follow-up data on patients' sperm count and paternity, information about the spouses and centralized laboratory for semen analysis and histopathology. Many of the patients had used medical therapy such as clomiphen, hormonal therapy, etc. and its effect could not be controlled. Still our study provides interes­ting data regarding the possibility of karyotype abnormalities and complications of surgical approach in varicocelectomy.

In conclusion, varicocele is a common disease, especially among primary and secondary in­fertile men and varicocelectomy may have some effects on sperm morphology, motility and the sperm count as well as on pregnancy. Varicocelectomy using subinguinal approach without microscopic assistance even with local anesthesia is a safe method with low morbi­dity. Future studies should address the issues of premature ejaculation and abortions in spou­ses and the role of varicocelctomy in impro­ving this.

 
   References Top

1.Redmon JB, Carey P, Pryor JL. Varicocele-The most common cause of male factor infertility? Hum Reprod Update 2002;8(1):53-8.  Back to cited text no. 1
    
2.Warburton D, Fraser FC. Spontaneous abortion rate in man data from reproductive histories collected in a medical genetic until. Am J Hum Genet 1963;16:1-25.  Back to cited text no. 2
    
3.Habibzadeh V. Incidence of spontaneous abor­tion in women referred to Kerman health cen­ters. J Shahid Sadoughi Univ Med Sci Health Serv 2001;3(8):88-92.  Back to cited text no. 3
    
4.Hoseini S, Beigi D, Khoshabi K. Pervalence of early ejaculation among infertile men referred to Rayan institute and society men. Articles abstract of Iran's 5th congress of Urology, Tehran. Iran university of medical sciences, p75,1381.  Back to cited text no. 4
    
5.Goldstein M. Surgical management of male infertility and other scrotal disorders. In: Walsh P, Wein A, Kavoussi L, Novick A, Partin A, Peters C. (eds). Campbell's Urology. 8th ed. Philadelphia. Saunders, 2002.1532-83.  Back to cited text no. 5
    
6.Sigman M, Howards SS. Male infertility. In: Walsh P, Retik A, Vaughan E, Wein A. (eds). Campbell's Urology. 6 th ed. Philadelphia. Sunders, 1992.661-93.  Back to cited text no. 6
    
7.Spink MS, Lewis GL. Albucasis on surgery and instruments. Great Britain. Oxford university press, 1927.438.  Back to cited text no. 7
    
8.Gat Y, Bachar GN, Zukerman Z, Belenky A, Gorenish M. Physical examination may miss the diagnosis of bilateral varicocele: A com­parative study of 4 diagnostic modalities. J Urol 2004;172(4):1414-7.  Back to cited text no. 8
    
9.Shafik A. The cremasteric Muscle: Role in varicocelogenesis and in thermoregulatory function of the testicle. Invest Urol 1973;11 (2):92-7.  Back to cited text no. 9
    
10.Marmar JL. Varicocele and male infertility: Part II the pathophysiology of varicoceles in the light of current molecular and genetic infor­mation. Hum Reprod Update 2001;7(5):461-72.  Back to cited text no. 10
    
11.Benoff SH, Millan C, Hurley IR, Napolitano B, Marmar JL. Bilateral increased apoptosis and bilateral accumulation of cadmium in in­fertile men with left varicocele. Hum Reprod 2004;19(3):616-27.  Back to cited text no. 11
    
12.Diamond DA, Zurakowski D, Atala A, et al. Is adolescent varicocele a progressive disease process? J Urol 2004;172(4 Pt 2):1746-8.  Back to cited text no. 12
    
13.Jarrow JP. Effects of varicocele on male fertility. Hum Repord Update 2001;7(1):59.  Back to cited text no. 13
    
14.Tulloch WS. Varicocele in subfertility: Results of treatment. Br Med J 1955;4935(1):356-8.  Back to cited text no. 14
    
15.Yamamoto M, Hibi H, Hirata Y, Miyake K, Ishigaki T. Effect of varicocelectomy on sperm parameters and pregnancy rate in patients with subclinical varicocele. J Urol 1996;155(5):1636-8.  Back to cited text no. 15
    
16.Schatte E, Hirshberg SJ, Fallick ML, Lipshultz LI, Kim ED. Varicocelectomy improves sperm strict morphology and motility, J Urol 1998; 160(4):1338-40.  Back to cited text no. 16
    
17.Belman AB. The adolescent varicocele. Pediatrics 2004;114(6):1669-970.  Back to cited text no. 17
    
18.Evers LH, Collins JA. Assessment of efficacy of varicocele repair for male subfertility. Lancet 2003;361(9372):1849-53.  Back to cited text no. 18
    
19.Salzhauer EW, Sokol A, Galassberg KI. Pater­nity after adolescent varicocele repair. Pediatrics 2004;114(6):1631-4.  Back to cited text no. 19
    
20.Steckel J, Dicker AP, Goldstein M. Relation­ship between varicocele size and response to varicocelectomy. J Urol 1993;149:769-71.  Back to cited text no. 20
[PUBMED]    
21.Braedel HU, Steffens J, Ziegler M, Palsky MS. Out-patient sclerotheraphy of idiopathic left sided varicocele in children and adults. Br J Urol 1990;65(5):536-40.  Back to cited text no. 21
    
22.Trussell JC, Haas GP, Wojtowycz A, landas S, Blank W. High prevalence of bilateral varico­celes confirmed with ultrasonography. Int Urol Nephrol 200 3; 35(1):115-8.  Back to cited text no. 22
    
23.Pasqualotto FF, Lucon AM, Hallak J, Goes PM, Saldanha LB, Arap S. Induction of sper­matogenesis in azoospermic men after vari­cocele repair. Hum Reprod 2003;18(1):108-12.  Back to cited text no. 23
    
24.Kadioglu A, Cayan S, Kandirali E, Tefekli A, Tellaloglu S. The results of varicocelectomy in azoospermic subfertile men with varicocele. J Urol 1999;161(4):282.  Back to cited text no. 24
    
25.Proyer J, Kent-First M, Muallem A, et al. Mic­rodeletions in the Y chromosomal of infertile men. N Engl J Med 1997;336(8):534-9.  Back to cited text no. 25
    
26.Cayan S, Erdemir F, Ozbey I, Turek P, Kadioglu A, Tellaloglu S. Can Varicocelec-tomy signifi­cantly change the way couples use assisted re­productive technologies? J Urol 2002;167(4): 1749-52.  Back to cited text no. 26
    
27.Daitch J, Bedaiwy M, Pasqualotto E, et al. Varicocelectomy improves intrauterine insemi­nation success rates in men with varicocele. J Urol 2001;165(5):1510-3.  Back to cited text no. 27
    
28.Koyle MA, Oottamasathien S, Barqawi A, Rajimwale A, Furness PD. Laparoscopic palomo varicocele ligation in children and adolescents: Results of 103 cases. J Urol 2004;172(4 Pt 2): 1749-52.  Back to cited text no. 28
    

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Correspondence Address:
Ali Shamsa
Department of Urology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad
Iran
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PMID: 21060180

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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