|Year : 2018 | Volume
| Issue : 1 | Page : 6-9
Short-term outcome of unaided versus microsurgical inguinal varicocelectomy among infertile men with varicocele
Muhammad Salihu Muhammad1, Ahmed Muhammed2, Ahmad Bello2, Ahmad Tijjani Lawal2, Awaisu Mudi2, Abdullahi Sudi2, Nasir Oyelowo3, Musliu Adetola Tolani3, Babatunde Kolapo Hamza3, Fidelis Lovely3, Hussaini Yusuf Maitama2
1 Department of Surgery, Division of Urology, Ahmadu Bello University Teaching Hospital, Zaria; Department of Surgery, Federal Medical Center, Bida, Niger, Nigeria
2 Department of Surgery, Division of Urology, Ahmadu Bello University Teaching Hospital; Department of Surgery, Ahmadu Bello University, Zaria, Nigeria
3 Department of Surgery, Division of Urology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Web Publication||28-Aug-2019|
Dr. Muhammad Salihu Muhammad
Department of Surgery, Division of Urology, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Objective: The objective was to determine the short-term outcome of unaided and microsurgical varicocelectomy on semen parameters and conception after 6 months in patients with infertility and varicocele. Patients and Methods: This was a randomized, prospective, interventional study that was conducted on men with infertility and varicocele. Patients were randomized into two groups. Patients in Group A underwent open inguinal varicocelectomy, whereas patients in Group B had the same surgery with microsurgical technique using ×3.5 magnification loupes. All the patients had preoperative seminal fluid analysis (SFA) performed on two occasions, a scrotal Doppler ultrasound and a postoperative SFA at 3 months and 6 months posttreatment. The data obtained were analyzed using the Statistical Package for the Social Sciences (SPSS) software package version 23.0, and the level of significance was taken as 0.05. Results: Thirty patients participated in the study, 14 in Group A and 16 in Group B. The mean age in Groups A and B was 40.07 ± 7.7 and 39.44 ± 7.3 years, respectively. About 85.7% of patients in Group A had bilateral varicocele, whereas 14.3% had left-sided varicocele. In Group B, 75% had bilateral, whereas 25% were on the left side. There was a statistically significant improvement in sperm count, motility, and morphology in both the unaided and the microsurgical groups; however, there was no significant difference in the improvement of seminal parameters between the two groups except the morphology. The pregnancy rate was 14.3% in Group A and 25% in Group B. Overall pregnancy rate in this study is 20% after 6 months. Conclusion: Varicocelectomy leads to significant improvement in sperm parameters; however, there is no significant difference in outcome between unaided and microsurgical varicocelectomy.
Keywords: Male infertility, sperm count, sperm morphology, sperm motility, varicocele, varicocelectomy
|How to cite this article:|
Muhammad MS, Muhammed A, Bello A, Lawal AT, Mudi A, Sudi A, Oyelowo N, Tolani MA, Hamza BK, Lovely F, Maitama HY. Short-term outcome of unaided versus microsurgical inguinal varicocelectomy among infertile men with varicocele. Afr J Infertil Assist Concept 2018;3:6-9
|How to cite this URL:|
Muhammad MS, Muhammed A, Bello A, Lawal AT, Mudi A, Sudi A, Oyelowo N, Tolani MA, Hamza BK, Lovely F, Maitama HY. Short-term outcome of unaided versus microsurgical inguinal varicocelectomy among infertile men with varicocele. Afr J Infertil Assist Concept [serial online] 2018 [cited 2020 Jun 2];3:6-9. Available from: http://www.afrijiac.org/text.asp?2018/3/1/6/265670
| Introduction|| |
Varicocele is a collection of abnormally dilated and tortuous testicular veins (pampiniform plexus). The term varicocele was originally coined by the British surgeon TB Curling in 1843. It is the most common attributable cause of primary and secondary infertilities in males., Varicocele is found in approximately 15% of the general population, 35% of men with primary infertility and 75%–81% of men with secondary infertility. Varicoceles are normally diagnosed by inspection and palpation of the spermatic cord before and during a Valsalva maneuver with a patient in both standing and recumbent positions. Doppler ultrasound is often used for the diagnosis of subclinical varicocele or confirmation of suspected varicocele. Varicoceles develop from a reversal of blood flow within the internal spermatic and cremasteric veins. There are three main anatomic explanations for origin of varicoceles. The first theory emphasizes the fact that the drainage of the testicular veins differs between the right and the left. While the right enters directly into the inferior vena cava at an oblique angle, the left joins the left renal vein at the right angle. The difference is thought to result in increased hydrostatic pressure on the left resulting in dilatation of the pampiniform plexus. The second theory postulates that an absence of competent valves leads to varicoceles. The final theory suggests that compression of the left renal veins between the aorta and the superior mesenteric artery increases the hydrostatic pressure in the testicular vein through a nutcracker effect.
The association between varicocele and infertility was first made by TS Tullock in 1952., Since then, several reports of similar findings have followed.,,, Various mechanisms have been proposed for infertility in men with varicocele. These include elevated testicular temperature, hypoxia and stasis, testicular venous hypertension, increase in spermatic vein catecholamine, and increased oxidative stress. These are thought to act either alone or in concert to impair spermatogenic epithelium and thus decrease spermatogenesis.
An association of abnormal seminal parameters in infertility with varicocele was first reported by MacLeod in 1965., These abnormal parameters include decreased sperm count, decreased motility, and increased abnormal forms. This picture is referred to as stress pattern or oligoasthenoteratozoospermia syndrome., Varicocele has been associated with ipsilateral testicular damage as reflected by a reduction in testicular volume which could adversely affect male fertility.,
The standard treatment for varicocele is varicocelectomy which involves ligation of testicular veins and is the most commonly performed operation for the treatment of male infertility. Surgical ligation can be achieved by conventional open varicocelectomy (retroperitoneal high ligation and inguinal and subinguinal ligations), laparoscopic/robotic varicocelectomy, and microsurgical varicocelectomy. Thus, this study aimed to determine the short-term outcome of unaided versus microsurgical varicocelectomy on semen parameters and conception after 6 months in patients with infertility and varicocele.
| Patients and Methods|| |
The study was a prospective interventional study, which was conducted over a period of 1 year from May 2015 to April 2016. It was conducted on male patients seen in the urology division of our hospital with infertility and clinically diagnosed varicocele in the absence of any other obvious cause of infertility. Approval for the study was obtained from the health research ethics committee of the hospital, and written informed consent was obtained from all the study participants.
Inclusion criteria were all consenting patients who satisfied the criteria outlined by the Practice Committee of the American Society for Reproductive Medicine in 2008. These include: the varicocele is palpable on physical examination of the scrotum, the couple has established infertility, the female partner has normal fertility or a potentially treatable cause of infertility, and the male partner has abnormal semen parameters or abnormal results from sperm function tests. Patients with other causes of infertility coexisting with varicocele, recurrent varicocele, and subclinical varicocele and those with azoospermia were excluded.
All patients were evaluated by obtaining a detailed history, duration of infertility, type (primary or secondary), risk factors for infertility, and past medical history. A focused physical examination was performed to determine the presence and grade of varicocele. The clinical parameters were entered into a pro forma. Seminal fluid analysis (SFA) was performed on two occasions preoperatively for each patient at least 7 days apart, after 3 days of abstinence in the same laboratory by a single examiner using the WHO Laboratory Manual for the Examination and Processing of Human Semen, Fifth edition (2010). Each patient also had a scrotal Doppler ultrasound to determine the size of both testes, confirm the varicocele, and measure the maximum diameter of the veins using the Mindray DC-8 Ultrasound Machine.
The enrolled patients were allocated to two groups (A and B) by simple randomization. The patients underwent open varicocelectomy through the inguinal approach either unaided (Group A) or with microsurgical technique using ×3.5X-L magnification loupes (Rose Micro Solutions, West Seneca, New York) (Group B). The surgeries were performed by the consultants and senior registrars in the unit. Regional anesthesia was used except when contraindicated or if it fails.
All the patients were discharged home within 48 h. The patients were followed up in the outpatient clinic to detect and treat any possible complication that may have arisen from the procedure and record the outcome variables. Each patient had a postoperative SFA at 3 months and 6 months.
The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software version 23.0 (SPSS version 23 IBM Corp, Armonk, New York). Dependent and independent paired t-tests were used to determine the relationship between the two groups. P <0.05 was considered statistically significant.
| Results|| |
A total of 30 patients met the inclusion criteria within the study period and were enrolled, out of which 14 had unaided varicocelectomy, whereas 16 patients had microsurgical varicocelectomy. The mean age of patients who had unaided varicocelectomy was 40.07 ± 7.7 years, whereas it was 39.44 ± 7.3 years for those who had microsurgical varicocelectomy [Table 1]. In Group A, 2 patients had left-sided varicocele, whereas 12 had bilateral varicocele. In Group B, the varicocele was bilateral in 12 patients, whereas the remaining 4 patients had left varicocele [Table 2].
In terms of sperm parameters, there was a statistically significant improvement in count, motility, and morphology in both the groups. In the unaided group, the mean sperm count increased from 7.1 million to 22.2 million, (P < 0.05); overall motility increased from 16.2% to 35%, (P < 0.05), and morphology increased from 19.1% to 37.3%, (P < 0.05). In the microsurgical group, the mean sperm count increased from 5.5 million to 22.7 million (P < 0.05); the mean motility increased from 23.6% to 48.3% (P < 0.05), whereas morphology increased from 28.3% to 55.9%, (P < 0.05) [Table 3].
|Table 3: Changes in semen parameters in both groups after varicocelectomy|
Click here to view
Two patients (14.3%) in the unaided group achieved pregnancy, whereas four patients (25%) in the microsurgical group were able to achieve pregnancy within the study period. Overall pregnancy rate was 20% [Table 4].
When the difference in outcome between the two groups is considered, only seminal morphology showed a statistically significant difference with a mean of 37.3% for Group A and 55.9% for Group B [Table 5].
| Discussion|| |
Varicocele is the most common, surgically remediable, attributable cause of primary and secondary infertilities in males., Although the association between varicocele and impaired spermatogenesis is well established, there is still considerable debate surrounding the optimal treatment approach. The lack of consensus is partly fueled by the variations in reported outcomes of the multitude of surgical and radiological options and variations in venous anatomy. Despite this, varicocelectomy is by far the most commonly performed operation for the treatment of male infertility.
In this study, the mean age of the patients is 39.7 years. This is similar to the mean age (35 years) found in the study by Okeke et al., among Nigerians. However, it is higher than the mean age (29 years) found by Almaramhy and Aly among Saudis in a similar study. There was no one with an isolated right-sided varicocele, a finding which is not unexpected, as several studies have highlighted the fact that varicoceles are more common on the left side,,,, and the discovery of an isolated right-sided varicocele should stimulate the search for a more sinister pathology.,
The results of this study demonstrated a statistically significant difference in improvement of pre- and postvaricocelectomy sperm parameters, that is, sperm count (concentration), motility, and morphology in the patients in both the unaided and the microsurgical groups. These results are comparable to those obtained by Hsieh et al., in a similar study on Chinese patients, in which there was a significant improvement in all the sperm parameters following varicocelectomy. Abdelrahman and Eassa in their study reported similar findings in the microsurgical group; however, there was no significant improvement in sperm parameters in the group who had unaided open varicocelectomy in their study.
When comparing the mean outcome of sperm parameters between the two groups in this study, only sperm morphology showed a statistically significant difference in the microsurgical group, which had a mean postoperative morphology of 58.9% as compared to a mean of 37.3% in the unaided group, though when analyzed individually, the improvement was significant in both groups as previously discussed. The overall outcome was, therefore, similar in both groups.
In terms of the ultimate outcome of treatment, which is pregnancy, the rate observed in the unaided group was 14.3% (2), whereas it was 25% (4) in the microsurgical group with an overall pregnancy rate of 20% in this study. This is similar to the result obtained by Jeje et al. in their study in Lagos, 18.6%. Ammo and Reddy et al. reported similar pregnancy rates of 21.8% and 19% among Iranians and Indians, respectively, after varicocelectomy., Mohamid also reported a similar rate of 26.9% among Egyptians. The pregnancy rate in this study is, however, lower than the rate reported by Osifo and Agbugui from Benin, 69.7%, and the 34.4% reported by Al-Ghazo et al., in their study from Jordan., This difference may be explained by the relatively short follow-up period of 6 months in this study. The main limitation of our study is the relatively short follow-up duration and a small sample size, further improvement in both sperm parameters and pregnancy rate may have been observed with a longer duration of follow-up.
| Conclusion|| |
This study shows that varicocele has a deleterious effect on sperm parameters, and varicocelectomy leads to significant improvement in all the parameters. There is no significant difference in outcome between unaided and microsurgical varicocelectomy, as both methods resulted in significant improvement in all seminal parameters.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Redmon JB, Carey P, Pryor JL. Varicocele – The most common cause of male factor infertility? Hum Reprod Update 2002;8:53-8.
Eisenberg ML, Lipshultz LI. Varicocele-induced infertility: Newer insights into its pathophysiology. Indian J Urol 2011;27:58-64.
] [Full text]
Sabanegh E Jr., Agarwal A. Male infertility. In: Alan J. Wein, Editor in Chief. Campbell Walsh Urology. 10th
ed. Philadelphia, PA: Elsevier Saunders; 2012. p. 616-47.
Ficarra V, Crestani A, Novara G, Mirone V. Varicocele repair for infertility: What is the evidence? Curr Opin Urol 2012;22:489-94.
Goldstein M. Surgical management of male infertility. In: Alan J. Wein, Editor in Chief. Campbell Walsh Urology. 10th
ed. Philadelphia, PA: Elsevier Saunders; 2012. p. 648-87.
Jarow JP. Effects of varicocele on male fertility. Hum Reprod Update 2001;7:59-64.
Scott LS. Varicocele: A treatable cause of subfertility. Br Med J 1961;1:788-90.
Osifo OD, Agbugui JO. Male infertility secondary to varicocele: A study of the management of 45 patients. Afr J Reprod Health 2008;12:54-9.
Cocuzza M, Sabanegh EA. Varicocele – A dilemma for the urologist current concepts. US Genitourin Dis 2007:2-7.
Fretz PC, Sandlow JI. Varicocele: Current concepts in pathophysiology, diagnosis, and treatment. Urol Clin North Am 2002;29:921-37.
Hassanzadeh-Nokashty K, Yavarikia P, Ghaffari A, Hazhir S, Hassanzadeh M. Effect of age on semen parameters in infertile men after varicocelectomy. Ther Clin Risk Manag 2011;7:333-6.
Practice Committee of American Society for Reproductive Medicine. Report on varicocele and infertility. Fertil Steril 2008;90:S247-9.
WHO Laboratory Manual for the Examination and Processing of Human Semen. 5th
ed. Genev; Switzerland: World Health Organisation; 2010. p. 223.
Abdelrahman SS, Eassa BI. Outcome of loupe-assisted sub-inguinal varicocelectomy in infertile men. Nephrourol Mon 2012;4:535-40.
Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM. Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial. Eur Urol 2011;59:455-61.
Okeke L, Ikuerowo O, Chiekwe I, Etukakpan B, Shittu O, Olapade-Olaopa O. Is varicocelectomy indicated in subfertile men with clinical varicoceles who have asthenospermia or teratospermia and normal sperm density? Int J Urol 2007;14:729-32.
Almaramhy HH, Aly M. Magnified and non magnified subinguinal varicocelectomy in infertile and/or symptomatic men: A comparative study of the outcome. Afr J Urol 2012;18:161-6.
Ammo KS. Sperm motility, concentration, morphology and pregnancy outcome post- varicocelectomy in Duhok. Duhok Med J 2012;6:21-8.
Reddy SV, Shaik AB, Sailaja S, Venkataramanaiah M. Outcome of varicocelectomy with different degrees of clinical varicocele in infertile male. Adv Androl 2015;2015:1-9.
Sangrasi AK, Leghari AA, Memon A, Talpur KA, Memon AI, Memon JM. Laparoscopic versus inguinal (Ivanissevich) varicocelectomy. J Coll Physicians Surg Pak 2010;20:106-11.
Agarwal A, Makker K, Sharma R. Clinical relevance of oxidative stress in male factor infertility: An update. Am J Reprod Immunol 2008;59:2-11.
Agarwal A, Prabakaran S, Allamaneni SS. Relationship between oxidative stress, varicocele and infertility: A meta-analysis. Reprod Biomed Online 2006;12:630-3.
Hsieh ML, Chang PL, Huang ST, Wang TM, Tsui KH. Loupe-assisted high inguinal varicocelectomy for sub-fertile men with varicoceles. Chang Gung Med J 2003;26:479-84.
Jeje EA, Alabi TO, Ojewola RW, Ogunjimi MA, Osunkoya SA. Male infertility: An audit of 70 cases in a single centre. Afr J Urol 2016;22:223-6.
Mohamid MA. The effect of magnified bilateral varicocele ligation on semen quality and the natural paternity rate in subfertile men, based on the sum of varicocele grading. Arab J Urol 2012;10:434-9.
Al-Ghazo MA, Ghalayini IF, al-Azab RS, Bani-Hani I, Daradkeh MS. Does the duration of infertility affect semen parameters and pregnancy rate after varicocelectomy? A retrospective study. Int Braz J Urol 2011;37:745-50.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]