The link between varicoceles and male infertility has been a matter of debate for more than half a century. Varicocele is considered the most common correctable cause of male infertility, but some men with varicoceles are able to father children, even without intervention. In addition, improvements in semen quality after varicocelectomy do not always result in spontaneous pregnancy. Studies regarding possible pathophysiological mechanisms behind varicocele-induced infertility have tried to address these controversies. Oxidative stress seems to be a central mechanism; however, no single theory is able to explain the differential effect of varicoceles on infertility. As a consequence, careful patient selection for treatment based on couple fertility status, varicocele grade, and semen quality is critical for achieving a chance of a subsequent pregnancy. A substantial amount of data on the effects of varicocelectomy has been gathered, but inadequate study design and considerable heterogeneity of available studies mean that these data are rarely conclusive. Current evidence suggests a beneficial effect of varicocelectomy on semen quality and pregnancy outcomes in couples with documented infertility only if the male partner has a clinically palpable varicocele and affected semen parameters.

Varicocele and male infertility

Authors' conclusions The body of the reviewed literature on cryptorchidism comprise primarily fairand poor-quality studies, which limits our ability to draw definitive conclusions. No specific imaging technique is able to completely identify anorchia or position of the undescended testicles and thus eliminate the need for further surgical evaluation. Accuracy of imaging is related to location of the testicles, with less invasive methods demonstrating poor accuracy for abdominally located testicles and those that are atrophied. Hormonal stimulation testing may predict anorchia, but evidence is insufficient, with only two studies of fewer than 50 participants. Hormonal treatment is marginally effective relative to placebo, but it is successful in some children and has minimal side effects, suggesting that it may be an appropriate trial of care for some patients. Surgical options are effective, with high rates of testicular descent (moderate strength of evidence for Fowler-Stephens procedures, high for primary orchiopexy). Comparable outcomes occur with laparoscopic and open approaches.

Evaluation and Treatment of Cryptorchidism

Objectives: To determine the effect of surgical varicocele repair in improving testicular Leydig cell function as shown by increased testosterone production.



Methods:  Eligible studies were searched in Medline and the Pubmed database, and cross-referenced as of 31 May 2011 using the terms “varicocele,”“testosterone” and “surgery.” The database search, quality assessment and data extraction were independently carried out by two reviewers. Only studies including patients with testosterone evaluation before and after surgery were considered for the analysis. A systematic review and meta-analysis was carried out for continues variables using random effect models.



Results:  Out of 125 studies, a total of nine were selected, including 814 patients. The combined analysis showed that mean serum testosterone levels after surgical treatment increased by 97.48 ng/dL (95% confidence interval 43.73–151.22, P = 0.0004) compared with preoperative levels.



Conclusions:  Surgical treatment of varicocele significantly increases testosterone production and improves testicular Leydig cell function.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1442-2042.2011.02890.x

Effect of surgical repair on testosterone production in infertile men with varicocele: a meta-analysis.

Impact of Varicocelectomy on Gonadal and Erectile Functions in Men with Hypogonadism and Infertility

Varicocele in infertile males is associated with Leydig cell dysfunction and hypogonadism. The effect of varicocelectomy on serum testosterone level is not yet established. We analysed 200 heterosexual infertile men diagnosed to have clinical varicocele they were divided into two groups: group 1 (100 men) had microsurgical varicocelectomy, and group 2 (100 patients) underwent assisted reproduction procedures. All participants had semen analysis, serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and total testosterone (TT), measured both at recruitment time and 6 months later. In group 1, the mean TT level increased significantly after varicocelectomy ( to  ng/dL, ) and testicular size correlated with the mean change in TT (). No similar change was found in group 2. Out of the 100 patients in group 1, 78 had postoperative normalization of TT unlike only 16 men in group 2.

/pdf/does-varicocelectomy-improve-gonadal-function-in-men-with-596c99lmie.pdf

Does Varicocelectomy Improve Gonadal Function in Men with Hypogonadism and Infertility? Analysis of a Prospective Study

The aim of our study was to assess the impact of patient age on sperm characteristics, and hormonal levels following varicocelectomy. We retrospectively reviewed the clinical records of 96 patients with a mean age of 28.1 years (range 18–48), who underwent microsurgical subinguinal varicocelectomy because of infertility, palpable swelling, or scrotal pain. These groups of patients were categorized into three age groups: group I, 18–25 years old at the time of varicocelectomy (n = 35 [36.5%]); group II, 26–35 years old (n = 43 [44.8%]); and group III, older than 36 years (n = 18 [18.8%]). Of the 96 patients, 68 attended the initial postoperative visit at 1 month and 96 attended the 6 months follow-up visit. Before surgery, no significant differences were seen among the three groups in sperm concentration, sperm motility and hormonal levels. After ligation, the sperm concentration and motility rates increased in all groups, but no significant differences were seen among the three groups for those parameters (P = 0.235 and P = 0.729, respectively). However, no significant changes in follicle-stimulating hormone, LH, testosterone levels were observed between each group. At sixth month of follow-up, two patients in group II, and a patient in group III, had persistent scrotal pain, and a patient in group I had varicocele recurrence; but no patients had hydrocele formation, evidence of testicular loss or progressive hypotrophy. The results of our study have shown that age is not a significant factor for outcomes of surgery and subinguinal microsurgical varicocelectomy in all aged patients has a similar high success rates.

The significance of age on success of surgery for patients with varicocele.

Objectives The aim of this study was to determine the relationship between urinary incontinence (UI) and parameters such as pregnancy, mode of delivery and other factors. Material and methods The study was based on a questionnaire administered to 761 patients. After their age, menopausal status, number of pregnancies, number of deliveries and history of connective tissue disease (CTD) were recorded, the data were analyzed using a chi2 test. Results In patients who are post-menopausal and over 40, both stress incontinence (SI) and urge incontinence (URI) were found to be significantly higher. It was also established that both SI and URI increased with the number of pregnancies. As the number of normal vaginal deliveries increased, the rate of both SI and URI increased, while increases in the number of cesarean sections affected neither SI nor URI. Among women who had had abortions, the rate of SI was higher, and it increased as the number of abortions increase. Neither the occurrence of abortions nor increased numbers of abortions influenced the rate of URI. In patients with CTD, both SI and URI increase. Conclusions Urinary incontinence in women seems to be influenced by the mode of delivery, menopause, age and CTD.

Urinary incontinence in women and its relation with pregnancy, mode of delivery, connective tissue disease and other factors.

Objectives: Placement of multiple nephrostomy tubes is the standard practice after completion of multitract percutaneous nephrolithotomy (PCNL) to reduce hemorrhage and urinary extravasation.We compared the outcomes among tubeless, single nephrostomy drainage and multiple nephrostomy drainage tubes following PCNL requiring multiple tracts. Methods: We retrospectively analyzed the data of 115 patients who underwent PCNL using multiple (two or more) access tracts. Patients were categorized into three groups: one nephrostomy tube for each tract (group 1, n = 43); single nephrostomy tube placement (group 2, n = 51), and no nephrostomy drainage with antegrade placement of a double-J stent (group 3, n = 21). Results: The three groups had comparable demographic data. The differences in operative times, average hemoglobin decrease and complication rates for the three groups were not statistically significant. The average hospital stay in the tubeless group (mean 2.1 days) was significantly shorter than that in group 1 (4.2 days) and group 2 (3.5 days). The postoperative analgesic requirement was significantly higher in group 1 compared to group 2 (p Conclusions: Single or no nephrostomy drainage following multitract PCNL offers the potential advantages of decreased postoperative analgesic requirement, and hospital stay without increasing the complications.

Comparison of nephrostomy drainage types following percutaneous nephrolithotomy requiring multiple tracts: single tube versus multiple tubes versus tubeless.

Erhan Sahin

Papers

The significance of age on success of surgery for patients with varicocele.

Urinary incontinence in women and its relation with pregnancy, mode of delivery, connective tissue disease and other factors.

Comparison of nephrostomy drainage types following percutaneous nephrolithotomy requiring multiple tracts: single tube versus multiple tubes versus tubeless.