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Asian Journal of Andrology 2016It was more than 40 years ago, as a first-year Urology resident, that I performed my first varicocele ligation (a Palomo procedure1) under the watchful eye and able...
It was more than 40 years ago, as a first-year Urology resident, that I performed my first varicocele ligation (a Palomo procedure1) under the watchful eye and able hands of my staff physician. I dutifully read all I could the night before the procedure and became familiar with the names of Barfield, Macomber and Sanders, Tulloch, MacLeod, Ivanissevich, Palomo, Amelar and Dubin and others who had written about varicoceles being associated with abnormal semen parameters and a potentially surgically correctable cause of male infertility. During and after our uneventful surgical procedure, I was grilled as to the anatomy and known pathophysiology of a varicocele. I felt well-versed from my reading and proudly regurgitated all I had learned about the anatomy of the left testicular vein and pampiniform plexus, incompetent or absent valves in the vein, increased testicular temperature, sluggish flow of blood from the left testis and possible toxins from the opposing left adrenal gland vein entering the dilated, incompetent testicular vein – any or all of which could contribute to disturb spermatogenesis and cause infertility. It all seemed simple enough! I pretty much thought we knew all we needed to know about this so-called “bag of worms.”
Topics: Humans; Male; Varicocele
PubMed: 26780874
DOI: 10.4103/1008-682X.172643 -
Andrology Sep 2018Varicocele is the most common abnormality identified in men being evaluated for subfertility. In this comprehensive review of the pathophysiology of varicocele, we will... (Review)
Review
Varicocele is the most common abnormality identified in men being evaluated for subfertility. In this comprehensive review of the pathophysiology of varicocele, we will shed light on novel pathophysiological findings and their clinical implications that may direct future researches; we will shed light on the impact of transient scrotal hyperthermia and the roles of inflammation and differential protein expression and androgen expression in spermatozoa on inducing pathophysiological findings. Furthermore, we will clarify the linked processes contributing to the pathophysiology of varicocele and the impact of genetics on the induction of these processes. Spermatogenesis is a temperature-sensitive process, and heat stress of varicocele is considered the most plausible cause of impaired spermatogenesis. The three processes associated with the presence of varicocele - heat stress, excess reactive oxygen species, and increased apoptosis - appear to be linked; heat stress is associated with increased levels of reactive oxygen species and oxidative stress, which can induce apoptosis. The genetic role should not be overlooked as a contributing factor in the induction of heat stress, excess reactive oxygen species/oxidative stress, and apoptosis; this is evidenced by the association of varicocele with decreased expression of heat-shock proteins, higher polymorphism of glutathione S transferase and nitric oxide synthase genes, and increased BAX and decreased BCL2 genes and proteins. In this article, we will highlight the need of application of novel diagnostic techniques that can provide a precise pathophysiological diagnosis to guide potential specific innovative therapies. Innovative therapies can counteract the varicocele-induced stasis, suppress the degenerative effects of testicular hyperthermia, reduce the varicocele-induced apoptosis, and target the elevated-neutrophil products aiming at abrogating the testicular damage caused by the induced varicocele in rats/mice. In conclusion, on the basis of the novel scientific research, it may be possible to formulate new treatments and achieve the appropriate selection of patients who can benefit from these treatments.
Topics: Animals; Apoptosis; Body Temperature; Cadmium; DNA Damage; Humans; Infertility, Male; Inflammation; Male; Reactive Oxygen Species; Receptors, Androgen; Spermatogenesis; Testis; Varicocele
PubMed: 29978951
DOI: 10.1111/andr.12511 -
Balkan Medical Journal Apr 2020Varicocele might cause deterioration in Leydig cell functions, and it is a significant risk factor for hypogonadism. Some controversial issues have been raised in the... (Review)
Review
Varicocele might cause deterioration in Leydig cell functions, and it is a significant risk factor for hypogonadism. Some controversial issues have been raised in the treatment of hypogonadal men with varicoceles. Symptomatic hypogonadal men with varicoceles have two options: testosterone replacement therapy or varicocele treatment. Both approaches have some advantages and disadvantages. This review summarizes the effect of varicoceles on total plasma testosterone level and addresses whether varicocele repair is effective to improve testosterone levels in hypogonadal men with varicoceles. Experience from large clinical studies in the literature suggests that varicocele repair may increase serum testosterone level in men with varicoceles and testosterone deficiency. Varicocele repair could be offered to men with clinically palpable varicocele and hypogonadism. As the treatment method, microsurgical varicocele repair could be preferred to provide the best improvement. Another advantage of varicocele repair for hypogonadism, instead of exogenous testosterone treatment, is its ability to preserve the fertility status in men who may desire a child in the future. However, further studies are required to clarify varicocel-related Leydig cell dysfunction and to advise hypogonadal patients about the sufficient effectiveness of varicocele repair.
Topics: Humans; Hypogonadism; Male; Risk Factors; Testosterone; Varicocele
PubMed: 32070086
DOI: 10.4274/balkanmedj.galenos.2020.2020.1.85 -
Fertility and Sterility Sep 2017Clinical varicoceles have been associated with impaired semen parameters and male-factor infertility. Varicocele repair can improve live birth rates for men with... (Meta-Analysis)
Meta-Analysis Review
Clinical varicoceles have been associated with impaired semen parameters and male-factor infertility. Varicocele repair can improve live birth rates for men with clinical varicocele. Varicocelectomy is often combined with assisted reproductive techniques (ART) such as intrauterine insemination (IUI), in vitro fertilization (IVF), or intracytoplasmic sperm injection (ICSI). Here we review the literature examining varicocelectomy before ART to evaluate whether improved pregnancy outcomes are realized. Although insufficient evidence exists to determine if correcting a varicocele improves IUI outcomes, a clinical benefit is observed when correcting a clinical varicocele in oligospermic and nonobstructed azoospermic men before IVF/ICSI. In couples seeking fertility with the use of ART, varicocele repair may offer improvement in semen parameters and may decrease the level of ART needed to achieve successful pregnancy.
Topics: Binding Sites; Comorbidity; Evidence-Based Medicine; Female; Humans; Infertility, Male; Male; Pregnancy; Pregnancy Outcome; Prevalence; Quality Improvement; Reproductive Techniques, Assisted; Risk Factors; Sperm Injections, Intracytoplasmic; Treatment Outcome; Urogenital Surgical Procedures; Varicocele
PubMed: 28865536
DOI: 10.1016/j.fertnstert.2017.06.033 -
Asian Journal of Andrology 2016In the past, the indications for varicocelectomy are primarily for infertility with abnormal semen parameters, testicular hypotrophy/atrophy in adolescents, and/or pain.... (Review)
Review
In the past, the indications for varicocelectomy are primarily for infertility with abnormal semen parameters, testicular hypotrophy/atrophy in adolescents, and/or pain. The surgical treatment of varicocele for hypogonadism is controversial and debated. Recently, multiple reports in the literature have suggested that varicocele is associated with hypogonadism and varicocele repair can increase testosterone levels. Men with hypogonadal symptoms should have at least two serum testosterone levels. Microsurgical varicocelectomy may be beneficial for men with clinically palpable varicoceles with documented hypogonadism. In this review, we summarize the most recent literature linking varicocele to hypogonadism and sexual dysfunction and the impact of repair on serum testosterone levels. We performed a search of the published English literature. The key words used were "varicocele and hypogonadism" and "varicocele surgery and testosterone." We included published studies after 1998. We, also, evaluated the effect of surgery on the changes in the serum testosterone level regardless of the indication for the varicocele repair.
Topics: Erectile Dysfunction; Humans; Hypogonadism; Male; Testosterone; Varicocele
PubMed: 26696437
DOI: 10.4103/1008-682X.169560 -
Fertility and Sterility Jan 2017Brown JS, Dubin L, Hotchkiss RS. The varicocele as related to fertility. Fertil Steril 1967;18:46-56. "The fact that some men with varicoceles are fertile should not...
Brown JS, Dubin L, Hotchkiss RS. The varicocele as related to fertility. Fertil Steril 1967;18:46-56. "The fact that some men with varicoceles are fertile should not minimize the potentially detrimental role of this abnormality. It would be reasonable to claim that varicocele is uniformly detrimental. One might postulate that a fertile man with a varicocele would have better semen without this condition."
Topics: Fertility; History, 20th Century; Humans; Infertility, Male; Male; Phlebography; Predictive Value of Tests; Risk Factors; Spermatic Cord; Varicocele; Veins
PubMed: 27842996
DOI: 10.1016/j.fertnstert.2016.10.018 -
Korean Journal of Urology Nov 2014Varicocele is the most common cause of male infertility and is generally correctable or at least improvable by various surgical and radiologic techniques. Therefore, it... (Review)
Review
Varicocele is the most common cause of male infertility and is generally correctable or at least improvable by various surgical and radiologic techniques. Therefore, it seems simple and reasonable that varicocele should be treated in infertile men with varicocele. However, the role of varicocele repair for the treatment of subfertile men has been questioned during the past decades. Although varicocele repair can induce improvement of semen quality, the obvious benefit of spontaneous pregnancy has not been shown through several meta-analyses. Recently, a well-designed randomized clinical trial was introduced, and, subsequently, a novel meta-analysis was published. The results of these studies advocate that varicocele repair be regarded as a standard treatment modality in infertile men with clinical varicocele and abnormal semen parameters, which is also supported by current clinical guidelines. Microsurgical varicocelectomy has been regarded as the gold standard compared to other surgical techniques and radiological management in terms of the recurrence rate and the pregnancy rate. However, none of the methods has been proven through well-designed clinical trials to be superior to the others in the ability to improve fertility. Accordingly, high-quality data from well-designed studies are needed to resolve unanswered questions and update current knowledge. Upcoming trials should be designed to define the best technique and also to define how to select the best candidates who will benefit from varicocele repair.
Topics: Fertility; Humans; Infertility, Male; Male; Urologic Surgical Procedures, Male; Varicocele
PubMed: 25405011
DOI: 10.4111/kju.2014.55.11.703 -
Fertility and Sterility Jul 1977Over the past 25 years the association of varicocele with male subfertility has been repeatedly demonstrated and the beneficial effect of varicocele ligation in... (Review)
Review
Over the past 25 years the association of varicocele with male subfertility has been repeatedly demonstrated and the beneficial effect of varicocele ligation in infertile men with oligoasthenospermia has been documented. Since the precise mechanisms by which a varicocele affects spermatogenesis are still unclear, the proper approach to the management of "asymptomatic" varicoceles is controversial.
Topics: Adult; Female; History, 16th Century; History, 19th Century; History, 20th Century; Humans; Infertility, Male; Leydig Cells; Male; Methods; Middle Aged; Pregnancy; Renal Veins; Semen; Spermatogenesis; Spermatozoa; Testis; United Kingdom; United States; Varicocele
PubMed: 326581
DOI: 10.1016/s0015-0282(16)42669-5 -
Andrologia Nov 2019Although varicoceles are a widely accepted identifiable male factor in infertile couples, the benefit of varicocele repair in improving pregnancy and live birth rates...
Although varicoceles are a widely accepted identifiable male factor in infertile couples, the benefit of varicocele repair in improving pregnancy and live birth rates remains uncertain. The Study for Future Families obtained semen and reproductive hormone samples from US men whose partners were currently pregnant. In our analysis cohort of 709 men, a varicocele was detected by clinical examination in 56 (8%) of men. Men with varicocele had smaller left testis, and lower total and total motile sperm counts than men without varicocele. Gonadotropin levels were higher as well in men with varicocele. Interestingly, testosterone levels were also slightly higher in men with varicocele. Despite these differences, there was no difference between the groups in the time to achieve the study pregnancy or percentage of men with a previous pregnancy. We conclude that even in fertile men, varicoceles are associated with some degree of testicular hypofunction. This would support current recommendations to consider varicocele repair in male partners in infertile couples who demonstrate both a varicocele and abnormal semen parameters and after evaluation for treatable female factors.
Topics: Adult; Cohort Studies; Female; Fertility; Gonadotropins; Humans; Male; Pregnancy; Prospective Studies; Semen; Semen Analysis; Testis; Testosterone; Varicocele
PubMed: 31448444
DOI: 10.1111/and.13407 -
Asian Journal of Andrology 2016A varicocele is defined as the abnormal dilation of the internal testicular vein and pampiniform venus plexus within the spermatic cord. If a semen analysis is not... (Review)
Review
A varicocele is defined as the abnormal dilation of the internal testicular vein and pampiniform venus plexus within the spermatic cord. If a semen analysis is not obtained from the adolescent male, in the absence of other symptoms, the main clinical indication used by many urologists to recommend repair is testicular atrophy. The varicocele may result in testicular damage in some males causing testicular atrophy with impaired sperm production and decreased Leydig cell function, while in other males the varicocele may seemingly cause no ill effects. In adult men, varicoceles are frequently present and surgically correctable, yet the measurable benefits of surgical repair are slight according to a Cochrane review. While occurring more commonly in infertile men than fertile men, only 20% of men with a documented varicocele will suffer from fertility problems. Most varicoceles found in adolescents are detected during a routine medical examination, and it is difficult to predict which adolescent presenting with a varicocele will ultimately show diminished testicular function in adolescence or adulthood. As in adults, the mainstay of treatment for varicocele in adolescents is surgical correction. However, unlike an adult varicocelectomy (the microsurgical approach is the most common), treatment for an adolescent varicocele is more often laparoscopic. Nevertheless, the goals of treatment are the same in the adolescent and adult patients. Controversy remains as to which patients to treat, when to initiate the treatment, and what type of treatment is the best. This review will present the current understanding of the etiology, diagnosis and treatment of the adolescent varicocele.
Topics: Adolescent; Adult; Age Factors; Humans; Male; Testis; Varicocele; Young Adult
PubMed: 26698233
DOI: 10.4103/1008-682X.167724