Bilateral microsurgical varicocelectomy in infertile men

We assessed how bilateral microsurgical varicocelectomy alters
semen quality in a large cohort of infertile men with bilateral varicocele.
By means of bilateral testicular biopsy, we have investigated
the spermatogenesis failure in several biological men groups and determined
whether it can change the patient's candidacy for assisted
reproductive technology procedures (ART).
Materials and methods. From 1993 until 2003 in the urology and
andrology department of St. Antoine hospital (1993-1994), the Tenon
hospital (1994-2003) and hospital Saint Louis (1997-2003), 956 patients
with varicocele were consulted and operated for primary or secondary
sterility. Bilateral varicocele was observed in 219 patients. Our
study included 198 patients with clinical palpable and infraclinical
(ultrasonic doppler scanning) bilateral varicocele who underwent
microsurgical bilateral varicicolectomy with bilateral testicular biopsy.
Mean patient age was 34.5 (range 19 to 65) years. Varicocele has been
classified into 4 stages. All the patients underwent a complete physical
examination, including supine and standing scrotal examination, as
well as testicular volume determination using a standard orchidometer.
Complementary investigation included: the hormone status
(FSH, LH, testosterone), semen analyses (carnitine, LDHx, fructoze,
zinc). On the basis of the total motile sperm count 198 patients were
divided into 5 biological groups: 10 azoospermia and oligospermia extreme
(0-1) x 106/cc - 83 patients (41.9%); 2) oligospermia severe
(1.1-5) x 106/cc) - 37 patients (18.7%); 3) oligospermia moderate
(5.1-10) x 106/cc) - 36 patients (18.9%). To measure the sperm quality,
the spermogram was studied 3, 6 and 12 months after the operation.
On the basis of testicular biopsy we defined the following spermatogenesis
groups: normal spermatogenesis - 9 cases, hypospermatogenesis - 141 cases,
maturation arrest (early-6, late-20), Sertli cell
only syndrome (SCOS) - 17, tubular and peritubular sclerosis -5. The
correlative analysis between the FSH classes and azoo- and oligospermic
subsets (83 patients) shows that azoo-oligospermic area as a
whole represents only 2 patients (2.4%) in the low FSH class, 46
(55.4%) in the normal FSH range class II, 39 (46.9%) patients in the
high FSH class III. All the patients were divided into 4 groups according
to the type of ART for which they qualified including 0 to
1.5 million/ml (intracytoplasmatic sperm injection-ICSI) - 79 patients,
1.5 to 5 million/ml (in vitro fertilization-1VF) - 33 patients, 5
to 20 million/ml (intrauterine insemination - IUI) - 47 patients and
20 million/ml or greater sperm (spontaneous pregnancy candidates)- 39 patients.
Results. Postoperative sperm concentration increased significantly
compared to the one before the varicocelectomy. In the group of
our patients the results were the following: of 198 patients 105 (53.1 %)
improved the spermogram, 44 (22.2%) worsened the spermogram, the
spermogram was not changed in 49 (24.8%). In the first biological
group of 83 patients, 42 (50.6%) improved the spermogram that enables
using several methods for this difficult group (ICSI, IVF) for
assisted reproductive technique (ART). The total amount of motile
sperm per ejaculation increased from (0.09+0.030) x 106 before varicocelectomy
up to (8.9+1.3) x 106 afterwards. In this group the testicular
biopsy shows different variants of spermatogenesis disturbances,
respectively. As for biological groups 3, 4 and 5, the observed spermogram
improvements sharply increased the patients' liability to
spontaneous pregnancy and make them intrauterine insemination
candidates.
Conclusions. Microscopic varicocelectomy has minimal morbidity
and recurrence and may be beneficial for certain patients. Making
simultaneous biopsy in patients with azoospermia and severe oligospermia
makes it possible to distinctly define the extent of spermatogenesis
disturbances and to elaborate adequate treatment policy.
The drastic improvement of the sperm quality after varicocelectomy
increases the ART chances for spontaneous pregnancy