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Varicocele repair benefits some infertile men with azoospermia

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – For some infertile men with nonobstructive azoospermia (NOA), varicocele repair leads to motile sperm in the ejaculate and spontaneous pregnancy, according to a meta-analysis published online April 19th in the Journal of Urology.

Men with more favorable testis histopathology — hypospermatogenesis or late maturation arrest — were more likely to ejaculate sperm after treatment than men with Sertoli-cell-only/germ cell aplasia, according to lead author Dr. John W. Weedin and colleagues of Baylor College of Medicine in Houston.

The authors note that 4.3% to 13.3% of men with azoospermia or severe oligospermia have varicoceles. They undertook their meta-analysis to assess the effect of varicocele repair on semen parameters and partner pregnancy rates, and to identify factors that might predict success.

The 11 studies in their analysis, involving 223 patients, were retrospective case series; no randomized controlled trial has been done. Five articles reported varicocele repairs performed microscopically through an inguinal approach, four reported procedures performed microscopically though a subinguinal approach and two described percutaneous embolization of the internal spermatic vein.

There were no reported surgical complications. Postoperative semen analysis found motile sperm in 91 men (39.1%). These men and their partners achieved 14 spontaneous pregnancies and 10 technology-assisted pregnancies.

Eleven patients (4.7%) with motile sperm relapsed to azoospermia within six months, leading Dr. Weedin’s team to advise that “semen cryopreservation be considered if motile sperm are detected postoperatively.”

According to the investigators, histopathology was the only statistically significant predictor of success and these results were generally consistent among the eight articles that reported outcome of varicocele repair related to histopathology.

Success after repair (defined as sperm in the ejaculate or spontaneous pregnancy) was significantly higher in patients with maturation arrest (42.1%) or hypospermatogenesis (54.5%) than in those Sertoli cells only, without germ cells (11.3%; p < 0.001 in both groups). Patients with late maturation also had a higher likelihood of success than those with early maturation (45.8% vs 0%; p = 0.007).

These findings mean that men with sperm precursors found on testicular biopsy, such as spermatids and spermatozoa, may benefit the most from varicocele repair, the authors suggest.

The research team advises that histopathology be considered before varicocele repair in men with NOA.

But an editorial, by Dr. Sandro C. Esteves, from ANDROFERT, Center for Male Reproduction, Campinas, Sao Paulo, Brazil, disagrees. Dr. Esteves notes that routine diagnostic testicular biopsy before varicocelectomy in men with NOA is a “controversial issue.” It has potential risks, such “inflammatory changes, hematoma, parenchymal fibrosis, and permanent devascularization of the testis.” It may also remove foci of spermatogenesis in an already compromised testicle.

In response, Dr. Weedin and colleagues say they believe diagnostic testicular biopsy before varicocele repair “is important despite the unusual risks.” Most men with NOA who wish to pursue biological pregnancy will still require in vitro fertilization with intracytoplasmic sperm injection (ICSI). Viable spermatozoa can be found during diagnostic testicular biopsy on wet mount or touch prep and can be used for immediate ICSI or frozen for future use.”

Reference:

J Urol 2010;183:2309-2315.