Varicocele and its effect on fertility
- Authors: Zamyatnin S.A.1,2, Gonchar I.S.3, Schmidt A.A.3
-
Affiliations:
- Military Medical Academy named after S.M. Kirov, Saint Petersburg
- Priozersk interdistrict hospital
- Military Medical Academy named after S.M. Kirov
- Issue: Vol 11, No 2 (2021)
- Pages: 105-112
- Section: Original articles
- URL: https://journals.eco-vector.com/uroved/article/view/34863
- DOI: https://doi.org/10.17816/uroved34863
- ID: 34863
Cite item
Abstract
Varicocele is recognized as one of the most common urological diseases, but its true prevalence is a matter of debate. In the present study, during a screening examination of 442 young men (mean age 21.6 years), grade I varicocele was detected in 7.2%, grade II – in 42.1%, and grade III – in 15.2% of men, varicocele was absent only in 35.5% of men. In 41% of cases, varicocele was diagnosed in isolation on the left side, in 36.5% of cases, bilateral varicocele was detected, and in 22.5%, varicose veins of the spermatic cord were detected on the right. Pathozoospermia was found in 47.3% of patients with grade II varicocele and 61.2% with grade III varicocele. The data obtained in the course of the study showed a significant effect of varicocele and its duration on sperm quality, in particular, on sperm morphology.
Keywords
Full Text
INTRODUCTION
Varicocele is an abnormal dilatation of the efferent veins of the pampiniform plexus, which causes one-third of all cases of male infertility [1–3]. This postulate, which until recently caused no doubts in the global medical community, in recent years has provoked discussions again. This was contributed by several publications that induced a different view of this problem [4–6], and the authors refer reasonably to the fact that the priority for couples with infertility is the birth of a healthy child and not the improvement of sperm quality. In this regard, adherents of this approach argue that the true influence of varicocele and varicocelectomy on fertility can be properly assessed only in those couples where female infertility is ruled out, but relatively few studies exist [6, 7]. Nevertheless, most andrologists recognize varicocele as one of the major causes of male infertility [8–10].
A review of literary sources revealed that varicocele is present in 15% of the entire male population. This pathology is often diagnosed at age 14–16 years, which is confirmed by the data of a large-scale study of schoolchildren. In this age group, available data present that varicocele was diagnosed in 9.5% of boys and in 11.8% of army conscripts aged 18–20 years during the prophylactic medical examination [9, 11]. In men with primary infertility, the frequency of the detection of the dilatation of the pampiniform plexus veins is much higher and, according to different studies, ranges from 19% to 40% of cases. In patients with secondary infertility, varicocele is diagnosed in 80% of cases, which confirms the theory of the significance of this pathology for male fertility [1, 2, 12–14].
The generally accepted notions indicate that the dilatation of the efferent veins of the pampiniform plexus develops mainly unilaterally on the left, and bilateral disease is diagnosed much less often (i. e., <10% of cases). An isolated right-sided pathological process is extremely rare and requires additional diagnostics to rule out retroperitoneal pathology [14–16]. Despite generally accepted foundations, some studies have reported that bilateral dilatation of the spermatic cord veins occurs in 38%–50% of cases [12, 17].
This study aimed to determine the incidence of varicocele in men aged <30 years, including bilateral and right-sided cases, and to analyze the effect of varicose veins of the spermatic cord on the development of pathozoospermia.
MATERIALS AND METHODS
A screening examination of 442 young men (cadets, group 1) aged 17–29 (average age, 21.6) years was performed. Group 2 included 63 patients (average age, 21.2 years) who underwent surgical treatment for grade II and III varicoceles. The efficiency of varicocelectomy was assessed after 12 months.
Depending on age, the patients in group 1 were stratified into six subgroups corresponding to the course of the study (Table 1).
Table 1. Distribution of representatives of the 1st group depending on age (n = 442) / Таблица 1. Распределение представителей 1-й группы в зависимости от возраста (n = 442)
Subgroup | Average age, years | Number of patients | |
n | % | ||
1 | 18.4 | 62 | 14.0 |
2 | 19.0 | 65 | 14.7 |
3 | 20.0 | 52 | 11.8 |
4 | 21.2 | 92 | 20.8 |
5 | 22.1 | 88 | 19.9 |
6 | 23.6 | 83 | 18.8 |
Total |
| 442 | 100.0 |
All men enrolled in this study underwent a comprehensive urological examination, including the spermogram; the results of which were analyzed in accordance with national clinical guidelines [3]. To identify varicose veins of the spermatic cord, all men underwent physical and ultrasound examinations of the scrotal organs. The grade of the varicocele was determined according to the conventional clinical classification of Lopatkin (1978): Grade I varicocele occurred when the dilated veins were not visible and palpable only during the Valsalva test. Grade II varicocele was diagnosed when the dilated veins of the pampiniform plexus were detected by visual assessment and palpation. Finally, grade III occurred if the testicular volume with dilated veins decreased. In all cases, the diagnosis of varicocele was confirmed by ultrasound data.
Statistical analysis of the research results was performed using Statistica v. 10.0 with the application of commonly used medical statistics methods. Differences were considered significant at p < 0.05.
RESULTS AND DISCUSSION
In this study, varicose veins of the spermatic cord were diagnosed in 285 (64.5%) men of group 1. Such a high prevalence of varicocele is apparently explained by conducting a survey of a limited cohort of young men (average age, 21.6 years). Grade I varicocele was detected in 32 (7.2%) patients, and grades II and III were identified in 186 (42.1%) and 67 (15.2%) patients, respectively (Table 2).
Table 2. The frequency of detection of pathozoospermia and normozoospermia in men of the 1st group (n = 442) / Таблица 2. Частота выявления патозооспермии и нормозооспермии у мужчин 1-й группы (n = 442)
Varicocele grade | Normozoospermia | Pathozoospermia | Total | |||
n | % | n | % | n | % | |
No signs of varicocele | 114 | 72.6 | 43 | 27.4 | 157 | 35.5 |
I | 24 | 75.0 | 8 | 25.0 | 32 | 7.2 |
II | 98 | 52.7 | 88 | 47.3 | 186 | 42.1 |
III | 26 | 38.8 | 41 | 61.2 | 67 | 15.2 |
Total | 262 | 59.3 | 180 | 40.7 | 442 | 100.0 |
The frequency of pathozoospermia detection in men with grade II and III varicoceles was quite high and accounted for 47.3% and 61.2% of the cases, respectively. In patients with grade I varicocele and in men without signs of varicose veins of the spermatic cord, the incidence of pathozoospermia was significantly lower and accounted for 25.0% and 27.4% of the cases, respectively. Laboratory signs of pathozoospermia were detected in all 63 patients of group 2 who underwent surgical treatment for grade II and III varicoceles.
The disease was detected mostly on the left side (41.0% of cases). Interestingly and very importantly, of all men examined, bilateral varicose veins of the spermatic cord were diagnosed in 36.5% of cases, and the isolated right-sided varicocele was found in 22.5% of cases (Table 3).
Table 3. Localization of varicocele in men of the 1st group / Таблица 3. Локализация варикоцеле у мужчин 1-й группы
Affected side | Varicocele grade | Total | ||||||
I | II | III | n | % | ||||
n | % | n | % | n | % | |||
Left-sided varicocele | 9 | 7.7 | 86 | 73.5 | 22 | 18.8 | 117 | 41.0 |
Right-sided varicocele | 12 | 18.8 | 42 | 65.6 | 10 | 15.6 | 64 | 22.5 |
Bilateral varicocele | 11 | 10.6 | 58 | 55.8 | 35 | 33.6 | 104 | 36.5 |
Total | 32 | 11.2 | 186 | 65.3 | 67 | 23.5 | 285 | 100.0 |
Our data are consistent with the findings of several major scientific studies published in recent years [11, 25] and indicate the need to continue research on this field, which may lead to the revision of current opinions.
Disease prevalence, clinical significance, and localization were analyzed in conjunction with the assessment of the qualitative and quantitative parameters of the spermogram. In this study, we did not found a significant correlation in the detection rate of pathozoospermia between bilateral and unilateral left-sided varicoceles (38.5% and 40.1%, respectively) (p > 0.1). Moreover, isolated right-sided pathozoospermia was found much less often, i. e., only in 20.4% of cases. All patients of group 2, who underwent surgery, were treated for left-sided varicocele.
The concept of pathozoospermia includes the pathological changes not only in the morphological structure of the spermatozoa but also the assessment of their mobility and concentration [18, 19]. Among 442 male patients examined, pathozoospermia was detected in 180 (40.7%) patients in group 1. Out of 157 men without signs of varicocele, 43 (27.4%) showed signs of pathozoospermia. The structure of pathozoospermia in the patients analyzed is presented in Figure 1.
Fig. 1. Structure of pathozoospermia in patients of the 1st group (n = 180) / Рис. 1. Структура патозооспермии у пациентов 1-й группы (n = 180)
To differentiate the effect of varicocele on various laboratory markers, we performed a detailed analysis of the morphological changes in the ejaculate and compared the changes according to the presence and severity of varicose veins of the spermatic cord.
Published studies have shown that the development of, for example, asthenozoospermia is often caused by a defect in the genome and, to a lesser extent, depends on varicocele [19]. Several andrologists believe that varicocele has a predominant effect on the development of teratozoospermia. In the present study, certain disorders of the morphological structure of spermatozoa were noted in 82.7% of the patients with varicocele and in 55.8% of men without varicocele.
The assessment of the influence of the affected side on the proportion of morphologically intact spermatozoa showed slightly worse indicators in bilateral cases compared with left-sided and right-sided varicocele; however, this difference was not significant.
As was shown earlier, pathozoospermia was significantly more often detected in patients with grade II and III varicoceles, mainly due to the presence of teratozoospermia. The proportion of morphologically healthy spermatozoa in patients with teratozoospermia decreased significantly if the patient has varicocele (Fig. 2).
Fig. 2. The proportion of morphologically healthy sperm in patients of the 1st group with teratozoospermia / Рис. 2. Доля морфологически здоровых сперматозоидов у пациентов 1-й группы с тератозооспермией
Our data confirm the detrimental effect of varicose veins of the spermatic cord on the quality characteristics of the ejaculate. Interestingly, when we analyzed the factors that worsened the morphological parameters of the ejaculate, we revealed a negative influence of the time factor, that is, the duration of the presence of the varicocele. In patients with grade II and III varicoceles, a negative correlation was found between the number of morphologically intact spermatozoa and the duration of varicocele within 6 years of follow-up. Thus, longer disease duration may worsen proportionally the morphology of spermatozoa. At 12 months after surgery, the results of the examination of patients revealed an increase in the proportion of morphologically healthy spermatozoa by an average of 1.9%.
CONCLUSION
Our data indicate a high incidence of not only left-sided varicocele but also bilateral and isolated right-sided varicocele. In all such cases, right-sided varicose veins of the spermatic cord can be a symptom of a serious retroperitoneal disease and, if necessary, require additional examination. Our data showed a significant effect of grade II and III varicoceles on sperm morphology. Thus, further study is necessary to determine the influence of disease duration on the morphology of sperm.
ADDITIONAL INFORMATION
Conflict of interest. The authors declare no conflict of interest.
About the authors
Sergey A. Zamyatnin
Military Medical Academy named after S.M. Kirov, Saint Petersburg; Priozersk interdistrict hospital
Author for correspondence.
Email: elysium2000@mail.ru
SPIN-code: 7024-0062
Doctor of Medical Sciences, Urologist. Department of Obstetrics and Gynecology, Chief physician
Russian Federation, 6 Academician Lebedev str., Saint Petersburg, 194044; 35, st. Kalinina, Priozersk, Leningrad region, 188760Irina S. Gonchar
Military Medical Academy named after S.M. Kirov
Email: bonechka@mail.ru
SPIN-code: 2768-7253
Candidate of Medical Science, Assistant of the Department of Obstetrics and Gynecology
Russian Federation, 6 Academician Lebedev str., Saint Petersburg, 194044Andrey A. Schmidt
Military Medical Academy named after S.M. Kirov
Email: ShmidtAA@mail.ru
SPIN-code: 4272-5069
Dr. Sci. (Med.), Professor, Head of the Department and Clinic of Obstetrics and Gynecology, Chief Gynecologist of the Ministry of Defense of the RF
Russian Federation, 6 Academician Lebedev str., Saint Petersburg, 194044References
- Agarwal A, Sharma R, Durairajanayagam D, et al. Major protein alterations in spermatozoa from infertile men with unilateral varicocele. Reprod Biol Endocrinol. 2015;13:8. doi: 10.1186/s12958-015-0007-2
- Panner Selvam MK, Agarwal A, Baskaran S. Proteomic analysis of seminal plasma from bilateral varicocele patients indicates an oxidative state and increased inflammatory response. Asian J Androl. 2019;21(6):544–550. doi: 10.4103/aja.aja_121_18
- Alyaev YuG, Glybochko PV, Pushkar’ DYu. Urologiya. Rossiiskie klinicheskie rekomendatsii. Moscow: GEOTAR-Media. 2016. 496 p. (In Russ.)
- Madykin YY, Zolotuhin OV. Varicocele and fertility disorders. Journal of New Medical Technologies. 2013;(2):269–270. (In Russ.)
- Shmidt АА, Zamyatnin SA, Gonchar IS, Korovin AE. Risk factors of the development of male infertiality. Clinical Pathophysiology. 2019;(4):41–45. (In Russ.)
- Shcheplev PA, Apolikhin OI. Muzhskoe besplodie. Obsuzhdenie konsensusa. Bulletin of Reproductive Health. 2010;(3–4):37–44. (In Russ.) doi: 10.14341/brh20103-437-44
- Majzoub A, Esteves SC, Gosálvez J, Agarwal A. Specialized sperm function tests in varicocele and the future of andrology laboratory. Asian J Androl. 2016;18(2):205–212. doi: 10.4103/1008-682X.172642
- Tanrikut C, Goldstein M. Varicocele repair for treatment of androgen deficiency. Curr Opin Urol. 2010;20(6):500–502. doi: 10.1097/MOU.0b013e32833f1b5e
- Artykov KP, Khuseynzoda D, Yuldoshov MA, Khvan IN. Actual problems of varicocele in adolescents. Avicenna Bulletin. 2020;22(2): 286–295. (In Russ.) doi: 10.25005/2074-0581-2020-22-2-286-295
- Pfeiffer D, Berger J, Schoop C, Tauber R. A Doppler-based study on the prevalence of varicocele in German children and adolescents. Andrologia. 2006;38(1):13–19. doi: 10.1111/j.1439-0272.2006.00680.x
- Gurevich AI, Menovshchikova LB, Petrukhina YuV, et al. Varikotsele u detei. Vsegda li nuzhno operirovat’? Pediatric and adolescent reproductive health. 2016;(2):66. (In Russ.)
- Gat Y, Bachar GN, Zukerman Z, et al. Varicocele: a bilateral disease. Fertil Steril. 2004;81(2):424–429. doi: 10.1016/j.fertnstert.2003.08.010
- Povoroznyuk MV. Varicocele as a cause of fertility dysfunction in men in sterile marriage. Reproductive health. Eastern Europe. 2014;5(35):139–146. (In Russ.)
- Osadchuk LV, Popova AV, Voroshilova NA. Infuence of prostatitis and varicocele on reproductive function of young men. Experimental and clinical urology. 2014;(2):77–81. (In Russ.)
- Chiba K, Ramasamy R, Lamb DJ, Lipshultz LI. The varicocele: diagnostic dilemmas, therapeutic challenges and future perspectives. Asian J Androl. 2016;18(2):276–281. doi: 10.4103/1008-682X.167724
- Tsukanov AJ, Semikina SP, Mustafayev RF. Varicocele as a manifestation of connective tissue dysplasia. Urologicheskie vedomosti. 2019;9(2):11–16. (In Russ.) doi: 10.17816/uroved9211-16
- Kapto AA. Endovascular surgery of the iliac veins with bilateral varicocele and varicose veins of the pelvic organs in men. Urologicheskie vedomosti. 2018;8(1):11–17. (In Russ.) doi: 10.17816/uroved8111-17
- Andreeva MV, Khayat SSh, Sorokina TM, et al. Types of pathozoospermia in men with infertility in marriage аnd/or disorders of reproductive system. Andrology and Genital Surgery. 2017;18(2): 33–38. (In Russ.) doi: 10.17650/2070-9781-2017-18-1-62-69
- Meshcheryakov YuV, Nikolaeva AS. Patofiziologicheskii puti razvitiya varikotsele-assotsiirovannogo besplodiya. Novoe slovo v nauke i praktike: gipotezy i aprobatsiya rezul’tatov issledovanii. 2016;(22):37–46. (In Russ.).