[Bilateral microsurgical varicocelectomy in infertile men]

Abstract

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 10(6)/cc--83 patients (41.9%); 2) oligospermia severe (1.1-5) x 10(6)/cc)--37 patients (18.7%); 3) oligospermia moderate (5.1-10) x 10(6)/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-IVF)--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 10(6) before varicocelectomy up to (8.9 +/- 1.3) x 10(6) 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.