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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 12  |  Page : 1744-1747

The Effect of Varicocelectomy on the Pregnancy Rate in Patients with Severe Oligospermia


Avrasya University, Faculty of Health Science; Department of Urology, Medical Park Karadeniz Hospital, Trabzon, Turkey

Date of Submission10-Apr-2020
Date of Acceptance25-May-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. H Turgut
Department of Urology Medical Park Karadeniz Hospital, Trabzon
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_173_20

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   Abstract 


Background: Varicocele is the most common correctable cause of male infertility. But, it is still controversial in patients with severe oligospermia. Aim: The aim of this study is to evaluate how varicocelectomy impacts pregnancy rates (natural or assisted reproductive techniques) in infertile couples when the male partner has severe oligospermia and history of varicocele. Materials and Methods: A retrospective examination was made of males with total motile sperm count <5 million/mL with varicocele in the period April 2013 to October 2019. Pregnancy rates were compared at the end of 1-year follow-up of 52 patients (Group 1) who underwent varicocelectomy and 36 patients (Group 2) who applied for assisted reproductive techniques without surgery. The postoperative third-month sperm parameters were compared for Group 1. Spontaneous pregnancy and conception rates with assisted reproductive techniques for Groups 1 and 2 were also investigated after 1 year. Results: In the semen analysis performed in the 3rd month, a statistically significant increase was observed in sperm number, motility, and morphology of the patients in Group 1. Spontaneous pregnancy was obtained in 7 (13.4%) of the 56 Group 1 patients who underwent varicocelectomy, in 7 (13.4%) patients with intrauterine insemination, and in 6 (11.5%) patients with intracytoplasmic injection (ICSI). In Group 2, pregnancy occurred with the help of ICSI in 4 of 32 patients (11.1%). Conclusions: Varicocele surgery before assisted reproductive techniques will be more beneficial in terms of both cost-effectiveness and pregnancy rates.

Keywords: Assisted reproductive techniques, infertility, varicocele


How to cite this article:
Turgut H. The Effect of Varicocelectomy on the Pregnancy Rate in Patients with Severe Oligospermia. Niger J Clin Pract 2020;23:1744-7

How to cite this URL:
Turgut H. The Effect of Varicocelectomy on the Pregnancy Rate in Patients with Severe Oligospermia. Niger J Clin Pract [serial online] 2020 [cited 2022 Nov 30];23:1744-7. Available from: https://www.njcponline.com/text.asp?2020/23/12/1744/304419




   Introduction Top


Varicocele is seen in 15% of the general population, and in 30%–40% of infertile men. There are many theories describing the negative effects of varicocele on testes and spermatogenesis, including pressure, oxygen deprivation, toxins, and the possible effect of heat. The gold standard of surgical treatment for clinical varicoceles is microsurgical varicocelectomy. Many studies have evaluated the effect of varicocelectomy in men with oligospermia.[1] However, the effects of varicocele on fertility in patients with severe oligospermia (sperm concentration <5 million/mL) are still controversial.[2] Few studies have evaluated outcomes of varicocelectomy in men with severe oligospermia.[2],[3]

Men with severe oligospermia are first counselled to undergo assisted reproductive technology (ART) with in vitro fertilization (IVF) because varicocelectomy may not improve semen parameters enough to achieve spontaneous pregnancy. Total motile sperm count (TMSC) is typically used to determine eligibility for IVF.[4] Men with TMSC <5million/mL are recommended to undergo IVF, those with 5–9 million/mL to undergo intrauterine insemination (IUI), and those with >9 million/mL are counselled to attempt natural pregnancy.[5]

It can be hypothesized that varicocele surgery has a positive effect not only on natural pregnancy but also on the outcome of assisted reproductive techniques in patients with severe oligospermia.

The aim of this study was to evaluate the birth rates following natural or assisted pregnancy in patients with severe oligospermia who were applied or not applied with surgery.


   Materials and Methods Top


After institutional review board approval was obtained (approval number: 2020/01-178), in a retrospective study conducted between April 2013 and October 2019, an evaluation was made of the sperm rates and gestational status of patients with clinical varicocele and severe Oligoasthenoteratospermia who presented at our clinic for reproductive assistance. A review was made of the data of 88 males with clinical varicocele. Patients included in the study were those with severe oligospermia (sperm concentration <5 million/mL) with either unilateral or bilateral clinical varicocele and a healthy female partner. Patients were excluded from the study if they had subclinical varicocele, hereditary disorders, primary hormonal disorders, ongoing use of medication that may affect fertility, history of testicular tumor and chemotherapy-radiotherapy, azoospermia, female factor infertility, or genetic abnormalities such as Klinefelter syndrome or Y-chromosome microdeletion, and females with any ailments for pregnancy.

Group 1 comprised 52 patients who underwent microsurgical subinguinal varicocelectomy under general anesthesia performed by a single surgeon (H.T) using a microscope with a magnification of × 10–×20. Spermiogram was evaluated in the third postoperative month.

Group 2 comprised 36 patients with varicocele and severe oligoastenoteratospermia who applied for assisted reproductive techniques (ART) but did not want surgery.

The cases of varicocele were identified by scrotal examinations performed by the same surgeon (H.T) with the patients in a standing position and during the Valsalva manoeuvre in a temperature-controlled room at over 23°C under adequate illumination. Scrotal Doppler ultrasound was performed on all patients to exclude other testicular pathologies (e.g., tumor, epididymitis). The disease was categorized into 3 grades: grade 1, if it was palpable just during the manoeuvre; grade 2, if it was palpable without the manoeuvre; and grade 3, if it was visible.

All patients with TMSC <5 million/mL underwent at least two semen analyses (SA). All semen analyses were performed in the same laboratory. Samples were obtained by masturbation after 3 to 5 days of sexual abstinence. After liquefaction of semen, standard variables (density, motility, and morphology) were obtained. Evaluations were also made of age, serum testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels. The postoperative third-month sperm parameters of the patients who underwent varicocelectomy were compared (Group 1). After 1 year, spontaneous pregnancy rates in Group 1 and Group 2, and conception rates with assisted reproductive techniques were investigated.

Statistical analysis

Data obtained in the study were analyzed statistically using SPSS vn. 20.0 software (SPSS, Chicago, IL, USA). Categorical variables were presented as percentages (%) and were analyzed using the Chi-square test. Continuous variables were shown as mean ± standard deviation (SD) values and were analyzed using paired and unpaired tests including the paired t-test, independent t-test, Mann–Whitney U-test, and the Wilcoxon Signed-Rank test according to normal distribution and the type of comparison.


   Results Top


The characteristics of the 88 primary infertile patients included in the study are shown in [Table 1] and [Table 2]. The mean age of the patients was 28.2 years (range: 21–37 years) in Group 1 and 29.6 years (range: 22–37 years) in Group 2. No statistically significant differences were determined between the two groups in respect of hormonal parameters, including FSH, LH, and testosterone levels, or the sperm parameters of sperm count, motility, and morphology. After 12 months of follow-up, the mean pregnancy rate was 38.5% (n: 20) and 11.1% (n: 4) for Groups 1 and 2, respectively. This difference was statistically significant. In Group 1, 13.4% (n: 7) of the pregnancies were normal spontaneous pregnancy, and 24.9% (n: 13) were the result of assisted reproductive techniques. All the pregnancies in Group 2 (11.1%, n: 4) were the result of assisted reproductive techniques [Table 3]. At postoperative 3 months, all the sperm parameters had increased compared to the preoperative values [Table 4].
Table 1: General information

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Table 2: Varicocele grade and side

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Table 3: The rate of pregnancy in study population

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Table 4: Sperm parameters of groups

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   Discussion Top


Varicocele is the most common correctable cause of male infertility. Men suffering from severe oligospermia with varicocele have several options if they wish to reproduce: to undergo varicocelectomy or not and then whether or not to pursue assisted reproductive techniques (IUI or ICSI-IVF). The aim of this study was to determine the role of varicocelectomy in primary infertile men with severe oligospermia (TMSC <5 million/mL) who wished to reproduce.

Many studies have shown significant improvements in semen parameters after varicocelectomy in infertile men with oligospermia (sperm count <20 million/mL),[6] but few studies have shown the results of varicocelectomy on severe oligospermia. Enatsu et al. examined the role of varicocelectomy in men with severe oligospermia, defined as TMSC <5 million/mL. In a total of 102 infertile men with severe oligoastenozoospermia, mean sperm concentration increased from 2.4 to 11.6 million/mL (P < 0.001) and mean sperm motility also increased.[2] In another study by Masterson et al. of patients with severe oligospermia (TMSC <5 million/mL), no statistically significant difference was observed in the semen analyses after surgery.[7] In the current study, a statistically significant increase was determined in all parameters (concentration, motility, and morphology) in the semen analysis at postoperative 3 months.

Men with TMSC <5 million/mL are challenging patients because many reproductive endocrinologists believe that their only chance of pregnancy is with IVF. Some studies have demonstrated that varicocelectomy can potentially improve semen parameters sufficiently to make couples eligible for less invasive forms of ART or even natural pregnancy.[8] However, in the guidelines of the European Association of Urology on male infertility, varicocele treatment for pregnancy is controversial.[9] The National Institute for Health and Clinical Excellence clinical guideline on fertility does not recommend varicocele surgery for men for infertility treatment because it does not increase pregnancy rates.[10] However, in the current study, even in patients with severe oligospermic varicocele, an increase in birth rates was observed with both spontaneous and assisted reproductive techniques after surgery.

Varicocelectomy is known to be a more advantageous procedure than assisted reproductive techniques in terms of cost-effectiveness, and it has been reported that IUI costs $50,000 more per varicocele per additional live birth.[11] Therefore, selecting this procedure initially before ART would be more economic, in addition to the satisfactory results achieved in the present study.

Sperm DNA fragmentation is one of the known causes of male infertility. Studies have shown that sperm DNA fragmentation decreases and fertility rate increases after varicocelectomy.[12] In the current study, sperm DNA fragmentation of patients was not examined, but any preoperative DNA damage may have improved after surgery. Thus, better quality sperm was obtained for ART, resulting in an increased pregnancy rate after surgery.

This study had both strengths and limitations. The strong aspects of the study are that all semen analyses were performed in the same laboratory and at least two semen analyses were evaluated. In addition, the pregnancy data is presented of men with severe oligospermia and all surgeries were performed by the same surgeon (H.T). To the best of our knowledge, there are few studies in literature that have compared the pregnancy rates and sperm parameters of patients with severe oligospermia (TMSC <5 million/mL) and varicocele.

Limitations of this study include the retrospective design and small sample size. In addition, the success rates for IVF-ICSI were also derived from a small sample size and a low number of total IVF-ICSI cycles. After surgery, it was not possible to obtain full information about the lifestyle of the patients (medical treatment for infertility, smoking, sports, etc.). Therefore, the effect of these changes on sperm parameters, either positively or negatively, could not be evaluated.


   Conclusions Top


Men with typically severe oligospermia and varicocele tend to undergo assisted reproductive techniques without varicocelectomy. The results of this study show that varicocelectomy increases TMSC in severely oligospermic patients and subsequently, the pregnancy rate. According to the increased sperm parameters, it was observed that pregnancy rates also increased in patients who had no chance of IUI previously. Therefore, it can be considered that performing varicocele surgery before assisted reproductive techniques will be more beneficial in terms of both cost-effectiveness and pregnancy rates.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Schlesinger MH, Wilets IF, Nagler HM. Treatment outcome after varicocelectomy. A critical analysis. Urol Clin North Am 1994;21:517-29.  Back to cited text no. 1
    
2.
Enatsu N, Yamaguchi K, Chiba K, Miyake H, Fujisawa M. Clinical outcome of microsurgical varicocelectomy in infertile men with severe oligozoospermia. Urology 2014;83:1071-4.  Back to cited text no. 2
    
3.
Smit M, Romijn JC, Wildhagen MF, Veldhoven JL, Weber RF, Dohle GR. Decreased sperm DNA fragmentation after surgical varicocelectomy is associated with increased pregnancy rate. J Urol 2010;183:270-4.  Back to cited text no. 3
    
4.
Borges Jr E, Setti AS, Braga DPAF, Figueira RCS, Iaconelli Jr A. Total motile sperm count has a superior predictive value over the WHO 2010 cutoff values for the outcomes of intracytoplasmic sperm injection cycles. Andrology 2016;4:880-6.  Back to cited text no. 4
    
5.
Samplaski MK, Lo KC, Grober ED, Zini A, Jarvi KA. Varicocelectomy to “upgrade” semen quality to allow couples to use less invasive forms of assisted reproductive technology. Fertil Steril 2017;108:609-12.  Back to cited text no. 5
    
6.
Kim KH, Lee JY, Kang DH, Lee H, Seo JT, Cho KS. Impact of surgical varicocele repair on pregnancy rate in subfertile men with clinical varicocele and impaired semen quality: A metaanalysis of randomized clinical trials. Korean J Urol 2013;54:703-9.  Back to cited text no. 6
    
7.
Masterson T, Greer A, Ramasamy R. Time to improvement in semen parameters after microsurgical varicocelectomy in men with severe oligospermia. Can Urol Assoc J 2019;13:E66-9.  Back to cited text no. 7
    
8.
Dubin JM, Greer AB, Kohn TP, Masterson TA, Ji L, Ramasamy R. Men with severe oligospermia appear to benefit from varicocelerepair: A cost-effectiveness analysis of assisted reproductive technology. Urology 2018;111:99-4.  Back to cited text no. 8
    
9.
Dohle GR, Colpi GM, Hargreave TB, Papp GK, Jungwirth A, WeidnerW. The EAU Working Group on Male Infertility. EAU guidelines onmale infertility. Eur Urol 2005;48:703-11.  Back to cited text no. 9
    
10.
National Collaborating Centre for Women's and Children's Health (UK). Fertility: Assessment and treatment for people with fertility problems: Clinical guideline February 2004.  Back to cited text no. 10
    
11.
Penson DF, Paltiel AD, Krumholz HM, Palter S. The costeffectiveness of treatment for varicocele related infertility. J Urol 2002;168:2490-4.  Back to cited text no. 11
    
12.
Rogue M, Esteves SC, Effect of varicocele repair on sperm DNA fragmentation: A review. Int Urol Nephrol 2018;50:583-603.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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