Oligospermia

Dr. Prateek Laddha
SR, Department of Urology
CMC Ludhiana

VARICOCELE
 Definition
 Etiology
 Pathophysiology of testicular changes
 Clinical features
 Investigations
 Treatment –
- Expectant treatment
- Indication of intervention
- Treatment options
- Complication of surgery
 Complication of untreated varicocele

DEFINITION
Dilated & tortuous veins of pampaniform plexus of spermatic cord
found in about 15% of male adolescents with a marked left sided
predominance

ETIOLOGY
Responsible factors
8-10 cm longer left testicular Vv. increased→
hydrostatic pressure in upright position
Entry of left testicular Vv into renal vein at 900
“Nutcraker phenomenon” due to passage of
left testicular vein between SMA & Aorta
Congenital absence of valve in left vein in
40%
Intrinsic ectasia of plexus due to cremaster
atrophy
Loaded left colon

PATHOPHYSIOLOGY OF TESTICULAR
CHANGES
Adverse effects on spermatogenesis –
 Reflux of renal and adrenal metabolites
 Hyperthermia
 Hypoxia
 Local testicular hormonal imbalance
 Intra testicular hyper perfusion injury
 Increased oxidative stress

HISTO-PATHOLOGICAL CHANGES
Both testes affected evenly by unilateral varicocele
 Tubular thickening
 Interstitial fibrosis
 Hypo-spermatogensis
 Maturation arrest
 Leydig cell dysfunction

CLINICAL FEATURES (SYMPTOMS)
 Asymptomatic - detected during medical
examination or evaluation of infertile male
 Constant dragging pain in Testis aggravated by
standing & relieved by lying down
 Impaired sperm quality
 Cosmetic attention
 Swelling in scrotum
 Failure of affected testis to grow

CLINICAL FEATURES (SIGNS)
Examine in warm room, standing & lying position, with or
without valsulva maneuver
 Painless compressible mass with feeling of “Bag of
worms”
 Small sized Testis on affected side

GRADES OF VARICOCELE
Grade I – Palpable only during valsulva
maneuver
Grade II – Palpable without Valsulva in
standing upright position
Grade III – Visible through scrotal skin
Subclinical – detected during USG

INVESTIGATION
 Doppler stethoscope (5.3 MHz probe) -audible rush of blood on
valsulva
 Colour Doppler –detects Sub Clinical Varicocele also
 Ultra sound of abdomen
 Semen examination

TREATMENT Expectant treatment – in adolescent males who are
asymptomatic with normal size of testis

INDICATION OF INTERVENTION
 Asymptomatic varicocele with >20% volume loss of Testis
(>2ml)
 Symptomatic varicocele
- Impaired sperm quality
- Pain
- Cosmetic reasons
 Medically unfit

TREATMENT ALTERATIVES(Obliteration of internal spermatic veins)
 Scrotal approach
 Inguinal approach (modified Ivanissevich)
 Retroperitoneal approach (Palomo’s)
 Sub inguinal approach
 Laparoscopic approach
 Per-cutaneous embolization – through trans
femoral/ trans jugular access (Detachable
balloons or steel coils are used)
 Micro Surgery
 Antigrade scrotal sclerotherapy (ASS)

COMPLICATIONS OF TREATMENT
 Hydrocele formation – due to ligation of lymphatics
 Recurrence
 Testicular infarction
 Migration of coil to pulmonary artery – usually not fatal
 Infection & haemorrhage

COMPLICATION OF UNTREATED
VARICOCELE
 Male infertility
 Testicular atrophy

LET US REVISE
 Definition
 Etiology
 Pathophysiology of testicular changes
 Clinical features
 Investigations
 Treatment
 Complication of untreated varicocele

 dilatation of the pampiniform venous plexus and
the internal spermatic vein
 well-recognized cause of decreased testicular
function
 very rare < 9 y.o.
 ~16% of adolescents
 ~15-20% of all males
 40% of infertile males
 scrotal varicoceles are the most common cause of poor
sperm production and decreased semen quality

The prevalence of varicocele and
associated testicular hypotrophy by age
Age, years Prevalence, %
of varicocele hypotrophic testis
<11 0 0
11–14 6–8 7.3
15–19 11–19 9.3

first recognized as a clinical problem in 16th
century
relationship between infertility and
varicocele proposed in late 19th century
 thereafter, others reported association with arrest
of sperm secretion and the subsequent restoration
of fertility following repair
enlarged scrotal veins in teenagers
referenced as early as 1885

1950s  report of fertility following
varicocele repair in an individual known to
be azoospermic
 surgical correction as clinical approach to certain
kinds of male infertility gained support among
American surgeons
Continued research documented recurrent
pattern of low sperm count, poor motility,
and predominance of abnormal sperm forms
(stress pattern of semen)
 not specific to varicocele
 suggests early evidence of testicular damage

80-90% involve the left testicle
 anatomic factors
(1) angle at which left testicular vein enters left renal vein
(2) lack of effective antireflux valves at juncture of testicular
vein and renal vein
(3) increased renal vein pressure due to compression
between the superior mesenteric artery and the aorta (ie,
nutcracker effect)
 35-40% of men with palpable left varicocele may
actually have bilateral varicoceles
 Recent study by Gat et al  ~ 80% of men with a
left clinical varicocele had bilateral varicoceles
revealed by noninvasive radiologic testing

Scrotal mass/swelling, symptoms of acute or
chronic scrotal discomfort, differing
testicular sizes without a palpable variocele,
and incidental finding on scrotal US
Grading:
 Grade 0 - Subclinical varicocele, Dx by US or
venography
 Grade 1 – palpable with Valsalva maneuver
 Grade 2 - Easily detected without Valsalva
maneuver
 Grade 3 - Detected visually at a distance

 Most asymptomatic
 usually unilateral and almost always left-sided
 unilateral right-sided varicocele should prompt
investigation for retroperitoneal process
 mass that causes obstruction of the right internal spermatic
vein
 Thrombosis/occlusion of the inferior vena cava must be ruled
out in
 Situs inversus another etiology of right-sided varicocele
 Initial presentation usually occurs during
puberty, with incidence in 13-year-old
adolescent boys equal to that of adult men

 Multiple investigators have directly correlated the degree of
testicular atrophy with varicocele grade
 Steeno et al  testis volume reduced by 81% with grade 3 and by
34% with grade 2
 No patients with grade 1 had testicular atrophy

 Unknown how impairment of sperm structure,
function, and production occurs
 interference with thermoregulation
 other theories include the possible effects of
pressure, oxygen deprivation, heat injury, and
toxins
 Despite considerable research, no one theory proved
unquestionably
 Regardless, indisputably a significant factor in
decreasing testicular function and in reducing
semen quality in large percentage of men seeking
infertility treatment

 Histologic studies  seminiferous tubule sclerosis, small
vessel degenerative changes, and abnormalities of Leydig,
Sertoli, and germ cells
 changes have been documented in patients as young as 12 years

 Presence of a varicocele does not necessitate
surgical correction
 Indications for surgical correction
 Relief of significant testicular discomfort or pain not
responsive to routine symptomatic treatment
 testicular atrophy (volume difference >20% or > 2cc)
 possible contribution to unexplained male infertility
 varicocele may cause progressive damage to testes,
resulting in further atrophy and impairment of seminal
parameters

 The AUA Male Infertility Best Practice Policy
Committee recommends treatment be offered to the
male partner when all the following are present:
 varicocele is palpable
 couple has documented infertility
 female has normal fertility
 one or more abnormal semen parameters or sperm function
test results
 men who have a palpable varicocele and abnormal
semen analyses findings but are not currently
attempting to conceive should also be offered
varicocele repair

 No strict criteria necessitate surgical intervention in
adolescents
 Each case handled individually
 discussion among patient, parents, and physician regarding
risks of intervention and potential impact on future fertility
 general guidelines used by some pediatric urologist
include the presence of one or more of the following:
 Varicocele associated with decreased ipsilateral testicular
size (20% volume deficit in the involved testis)
 Bilateral varicoceles
 Symptomatic painful varicocele
 Abnormal findings on semen analysis

Lipshultz and Corriere (1997)
 suggested that varicoceles were associated with
testicular atrophy that was progressive with age
 observed that testicular biopsy specimens taken
from prepubertal boys with varicoceles already
revealed histologic abnormalities
Kass and Belman (1987)
 first to demonstrate significant increase in
testicular volume after varicocele repair in
adolescents
 did not study semen parameters

 ideal technique is to ligate all of the internal and
external spermatic veins with preservation of
spermatic arteries and lymphatics
 internal spermatic artery may be divided with
transperitoneal or retroperitoneal approach
 does not usually cause testicular atrophy due to generous
collateral circulation to testicle
 3 most common surgical approaches
 inguinal
 Retroperitoneal
 subinguinal

 Surgical Treatment can be divided into 3 main
categories
 Diagnostic procedures
 Testis biopsy
 Seminal vesicle aspiration
 vasography
 Procedures to improve sperm production
 Varicocelectomy
 Procedures to improve sperm delivery
 Vasovasostomy
 Vasoepididymostomy

 Varicoceles are now recognized as the most surgically
correctable cause of male infertility.
 They are present in 15% of the normal male population.
 Up to 40% of patients with male infertility.
 Approximately 70% of patients with secondary infertility have been found to have
a varicocele as an underlying cause.
 Varicocele repair remains the most cost-effective procedure in
helping a subfertile man establish a pregnancy.
 improve spermatogenesis
 increase serum testosterone
 Vasectomies
 ½ million performed per year. 75% by urologist
 12% of men aged 20 to 39 years in the United States have had a vasectomy
 6% will eventually desire a reversal

 Testicular Biopsy
 Azoospermia with normal FSH and normal sized
testicles.
 Can be due to obstruction, defect in spermatogenesis, or incomplete
defect
 Obstruction vs. spermatogenic failure?
 Can also be therapeutic - consider sperm retrieval for IVF/ICSI.
 Should be perform on both testes for
nonobstructive azoospermia.
 In obstructive azoospermia, should biopsy the
larger testis first.

 Testicular Biopsy
 Open
 Percutaneous

1. Cord block with 1% lidocaine and
0.25% bupivicaine with 30-ga needle
2.The scrotal skin and tunica vaginalis are
then infiltrated with 2 mL of 1% lidocaine
with a 30-ga needle.
3. A 1- to 2-cm transverse incision is made
to the parietal tunica vaginalis through
the anesthetized region.
4.The tunica vaginalis is then opened
with scissors, and the edges are grasped
and held apart with two small hemostats
or a small self-retaining eyelid retractor.
Lidocaine (2 to 3 mL) is dripped onto the
exposed tunica albuginea to anesthetize
the testicular surface where the biopsy
specimen will be taken.

5.The tunica albuginea is carefully inspected
for the least vascular area for the incision. A 5-
0 Prolene suture is passed at one end of the
proposed site of incision in the testis.
6. A 4- to 5-mm incision is made in the tunica
albuginea by use of a No. 11 scalpel or a
microknife, allowing extrusion of the
seminiferous tubules.
7.With the "no-touch" technique, fine, sharp
iris scissors are used to carefully excise the
extruded tubules.
8.The specimen is then placed in Zenker's,
Bouin's, or buffered glutaraldehyde solution.
The testicular specimen should not be placed
in formalin.
9. “Touch imprint” or wet prep done.Touch
imprint more predictive in the evaluation of
spermatogenesis.

10. If sperm are found and
cryopreservation of testicular
tissue is to be done, additional
testicular tissue can be taken
from the same site and placed
in appropriate medium in
individual Eppendorf tubes for
processing by the andrology
laboratory.
11.The incision is then closed
with the previously placed 5-0
Prolene suture. It is important to
close the tunica vaginalis over
the testis with absorbable
suture, such as 4-0 chromic or
Vicryl.

1. Percutaneous testicular biopsy
can be performed with local
anesthesia in an office-based
setting, and it is generally
associated with less pain and
morbidity than an open
testicular biopsy.
2. A 95% correlation was
described between
percutaneous needle and open
biopsy techniques as long as
sufficient materials are present
for diagnosis.
3. Before the biopsy is performed,
the skin is punctured with a
scalpel to prevent inclusion of
scrotal skin with the specimen.
4. To avoid injury to the
epididymis and the surgeon's
hand, the point of the needle
insertion should be from the
lower pole toward the upper
pole.

 Hematoma
 Testicular atrophy – rare
 Inadvertent epididymal biopsy

 15% of the normal male population and in up to 40% of patients with male infertility
 World Health Organization reported that varicoceles were found in 25.4% of men with abnormal
semen parameters compared with 11.7% of men with normal semen.
 Varicoceles have been associated with impaired semen quality and decreased Leydig cell
function.
 However, varicocele repairs have been shown to improve not only spermatogenesis but also
Leydig cell function
 most commonly performed surgical procedure in treatment of male infertility.
 Grading of Varicocele
 I - Palpable only with the Valsalva maneuver
 II - Palpable without the Valsalva maneuver
 III - Visible through the scrotal skin
 Repair of larger varicoceles results in significantly greater improvement in semen quality
than does repair of smaller varicoceles.
 On scrotal US – dilated veins > 3.5 mm
 Subclinical varicoceles
 Diagnosed only on US
 Studies have demonstrated that subclinical varicoceles have no impact on fertility and that
repair of subclinical varicoceles does not improve fertility rates.

 Four indications for treatment in adult men
 The couple has known infertility
 The female partner has normal fertility or a potentially treatable cause of
infertility
 The varicocele is palpable on physical examination, or if it is suspected, the
varicocele is corroborated by ultrasound examination
 The male partner has an abnormal semen analysis
 In adolescent men
 Reduction in ipsilateral testicular size, otherwise observation and /or semen
analysis.

 Surgical Approaches
 Scrotal
 No longer used. High failure rate and testicular artery injury risk.
 Retroperitoneal
 Palomo
 High retroperitoneal ligation of the internal spermatic vein above the internal inguinal ring.
 A common complication of the retroperitoneal approach is varicocele recurrence or
persistence, estimated to be between 11% and 15%.
 The recurrence can be significantly reduced by intentional ligation of the testicular artery.
This is thought to ensure ligation of the periarterial/cremasteric veins and thus to prevent
recurrence.
 Laparoscopic
 Excessively invasive for what should be a minor outpatient procedure
 laparoscopic varicocele repairs have been associated with a recurrence
rate of less than 2% and formation of hydroceles in 5% to 8% of patients

 Inguinal and subinguinal approach
 Preferred approaches
 Less morbidity associated with the subinguinal (infrainguinal) approach
than with the laparoscopic and inguinal approach because of the
preservation of the muscle layers and the inguinal canal
 However, a greater number of internal spermatic veins and arteries lie
below the external ring, making this procedure technically more
challenging

1. Essentially the same as the
Palomo technique.
2. Establish
pneumoperitoneum using
Veress or Hassan technique.
3. Parietal peritoneum is
incised just lateral to the
spermatic cord.The
testicular artery and veins
are dissected and isolated.
Pulling on the testis can help
identify the vessels.
4. Once the veins are isolated,
they are clipped both
proximally and distally with
titanium endoclips, and
these vessels are then
transected.

1. 3- to 4-cm oblique incision, two
fingerbreadths above the
symphysis pubis and just above the
external ring, is carried laterally
along Langer's lines
2. Incision is carried down to the
external oblique aponeurosis,
which is incised in the direction of
its fibers. Care is taken to identify
and to preserve the ilioinguinal
nerve .
3. The spermatic cord is mobilized
near the pubic tubercle, and a
Penrose drain is passed beneath
the cord.The Penrose drain is used
to elevate the cord and bring it
through the incision.
4. (+/-) microscope/loupes
5. Varicoceles generally appear with
a typical vascular pattern in which
the artery is next to or adherent to
several veins, and there is a
separate isolated vein nearby.

6. Once the dilated veins are isolated, they are
doubly ligated with either 2-0 silk sutures or
small titanium surgical clips.
7.With the microsurgical technique, the
lymphatic channels can be clearly visualized,
and these should be preserved to prevent
postoperative hydrocele formation.
8.The floor of the inguinal canal, near the
external ring, should also be inspected to
identify and ligate any external cremasteric
veins.
9.The cord is placed back into the canal, and
the external oblique fascia is closed with a 3-0
Vicryl suture.The subcutaneous layer is
reapproximated with a 3-0 plain catgut suture,
and the subcuticular layer is closed with a 4-0
Monocryl suture.The incision is infiltrated with
1% lidocaine mixed with an equal amount of
0.5% bupivacaine.

 Percutaneous Embolization
 Cut-down to femoral or internal jugular vein
 embolization of the spermatic veins can be accomplished with coils,
balloons, or sclerotherapy
 Overall success rate – 68%
 Percutaneous varicocele embolization is especially useful in a recurrent or
persistent varicocele, when the anatomy causing the varicocele needs to be
radiographically clarified.

 Outcomes
 studies have shown that repair of varicoceles can retard further damage to
testicular function
 overall rate of improvement in semen parameters after varicocelectomy
ranged from 51% to 78%
 improve not only semen motility, density, and morphologic features but also
serum FSH and testosterone levels
 No difference noted between laparoscopic and open approach, but higher
complications in the lap. Group
 Predictors of successful repair
 Sperm concentration > 5million/ml or density > 50 million per ejaculate
 lack of testicular atrophy
 sperm motility of 60% or more
 serum FSH values less than 300 ng/mL (normal, 50 to 300 ng/mL)

 Probability of a live birth after a varicocelectomy was 29.7% versus 25.4% after
IVF-ICSI.
 The cost per delivered baby was $26,268 after varicocelectomy compared with
$89,091 with IVF-ICSI.

 6% of men who have undergone vasectomy will subsequently request a
vasectomy reversal
 Chances for success (patency or pregnancy) based on the personal experience
of the surgeon, the patient's health history, and the results of examination of the
man and the age and reproductive potential of his partner are discussed.
 Epididymal obstruction appears, in most instances, to be a time-related
phenomenon
 62% of patients who underwent reversal 15 years or more after their
vasectomy required either a unilateral or a bilateral vasoepididymostomy
 VE depends on quality of fluid from proximal vas
 when the material coming from the proximal vas lumen is thick, pasty,
and devoid of sperm; if the fluid is creamy, containing only debris.
 microsurgical vasectomy reversal are superior to results of nonmicrosurgical
techniques
 No significant difference if a multilayer anastomosis is performed as opposed to
a modified single-layer technique but the success is physician-dependent.

A. Nonlocking needle holder.
B.Suture scissors.
C.Dissecting scissors.
D,E. Very fine pointed and
round-tipped scissors.
F.Round-handled platform
forceps.
G.Curved dilating forceps.
H.Round-handled small knife
blade holder.
I.Microtip bipolar cautery

Anesthetic Considerations
1.General vs. local?
2.Preparing the vas for anastomosis
1. Vas grasped through skin
above the vasectomy site.
2. Once the vas is exposed,
injection of a mixture of
0.5% bupivacaine and 1%
lidocaine into the distal
perivasal sheath will
provide sufficient
anesthetic coverage for
the vasal anastomosis to
be performed.
3. Placement of 6-0 Prolene
sutures just into the
muscularis holds the vas
above the incision and
make it easily accessible
for anastomosis.

4.The vas above and below the vasectomy site
should be transected with use of the operating
microscope Once the point of the vas that is to
be cut is chosen, the vasal vessels are secured
with 7-0 Prolene sutures just proximal to the
point of transection. Some experienced
microsurgeons prefer to cut the vas deferens
through the groove of a nerve-holding forceps
to ensure a straight cut.
5. A few drops of fluid from the testicular end
of the vas lumen are placed on a sterile glass
slide and examined by light microscopy.
6. If there are sperm or sperm parts (sperm
heads, sperm with partial tails) in large
numbers or the fluid is clear and copious with
no visible sperm, vasovasostomy is generally
indicated. If the fluid is thick, pasty, and devoid
of sperm or contains only a few sperm heads,
vasoepididymostomy should be considered.

1. The anastomosis is begun by
passing a 9-0 suture through
the muscularis and the
adventitia at the 5- and 7-
o'clock positions .
2. A double-armed 10-0 suture
is passed through the lumen
at the posterior 6-o'clock
position and tied.
3. The next sutures are placed
in the wall of the lumen on
either side of the first.These
sutures are tied after both
are in place.
4. Three to five more sutures
are placed equidistant from
one another to close the
remainder of the lumen but
are left untied until all the
sutures have been placed.

5. Once the anastomosis of
the lumen has been
completed, the 9-0 suture
is again used to bring the
muscularis together. A
suture is placed at the 12-
o'clock position first, then
sequentially around the
cut end of the vas until the
first two sutures are
reached .
6. The adventitia is brought
together over the
muscularis suture line with
interrupted 9-0 sutures to
further enhance the blood
supply at the level of the
anastomosis.

1. A double-armed 10-0 suture
is passed full thickness
through the edge of the
proximal and distal lumen at
the 6-o'clock position.
2. Two more sutures are
placed, full thickness, at the
4- and 8-o'clock positions
and tied.
3. Three more full-thickness
sutures are passed at the 10-,
12-, and 2-o'clock positions
and then tied.
4. The anastomosis is
completed by closing the
muscularis and adventitia to
the opposite side, placing
two 9-0 sutures between
each of the 10-0 full-
thickness sutures.

 Consider sperm retrieval/cryo during vasovas
 8-14% of pts. Use their cryopreserved sperm
 Can always do testis biopsy and sperm extraction at a later date.
 Post-op Care
 Moderate activity for the first week after surgery and to refrain from heavy
exercise and sexual activity for 3 weeks. Examination of the semen occurs at
1 month and every 3 months in the year after surgery. Most patients will
have sperm in their semen within 4 weeks after vasovasostomy.
 If sperm are not present by 6 months, the operation is considered a failure.
 Repeated surgery or sperm retrieval and IVF-ICSI may be offered.
 Complications
 Secondary obstruction and consequent azoospermia after initially successful
vasovasostomy have been reported to occur in 3% to 12% of men.
 marked decrease in motility and the appearance of sperm heads along with some normal sperm

Years of
Obstruction
Patency (%),
Sperm Present Pregnancy (%)
<3 86/89 (97) 56/74 (76)
3-8 525/600 (88) 253/478 (53)
9-14 205/261 (79) 92/209 (44)
≥15 32/45 (71) 11/37 (30)

 Epididymal Obstruction
 Can be idipathic, inflammatory, iatrogenic, congenital.
 Time-dependent with vasectomy.
 Decision to perform a vasoepididymostomy is based primarily on the quality
of fluid found at the proximal (testicular) vas.
 3 microsurgical techniques
 Direct end-to-end
 End-to-side
 End-to-side intussusception
 Pre-op Consideration
 General/epidural anesthetic
 Cryopreserve sperm?
 Patient positioning/comfort/safety

1. Testis biopsy to
confirm
spematogenesis.
2. Incision is enlarged
and the testis
delivered out of the
scrotum and
examined. In most
instances, the
epididymis will be
visibly dilated, even
without optical
magnification .
3. Mobilize the distal vas.
4. Confirm vasal patency
with vasography.

1. The epididymal tail can be dissected
free from the inferior aspect of the testis
and the epididymis transected at its
distal end.
2. When the epididymis is cut proximal to
the obstructed area, there will be a
continuous flow of sperm-laden fluid
from one opened epididymal tubule.
3. The lumen of the vas deferens is
anastomosed to the cut, open tubule
exuding sperm.The first step is to
secure the cut end of the abdominal vas
to the epididymal tunic with two 9-0
nylon sutures passed through the edge
of the epididymal tunic and into the
adventitia and muscularis of the vas
deferens at the 5- and 7-o'clock
positions. Four equally spaced double-
armed 10-0 sutures are placed into the
edge of the epididymal tubule, inside
out, and then carried through the vas
lumen, beginning at the 6-o'clock
position.The first suture is tied, but the
sutures at the 3-, 9-, and 12-o'clock
positions are not tied until all are
placed.

4.The muscularis and
adventitia of the vas deferens
are secured to the tunic of
the epididymis with
interrupted 9-0 sutures .

1. The rationale is that there is
far less dissection required,
less troublesome bleeding
from the transected
epididymis, and therefore a
clearer field.
2. Beginning at the level of the
cauda, a 0.5-cm incision is
made in the tunic of the
epididymis, pushing the
tubule toward the tunic
surface.
3. The anterior surface of this
loop is incised along its
longitudinal axis with a
microknife, making an
opening of approximately
0.5 mm.
4. Fluid is examined for
normal-appearing sperm.

5. Once the patent loop is
identified and opened, three
10-0 double-armed sutures are
placed (inside-out) in a
triangular fashion equidistant
from one another
6.The vas deferens is brought
through the uppermost
portion of the tunica vaginalis .
7.Two 9-0 nylon sutures are
used to hold the muscularis
and adventitia of the vas
deferens to the opened
epididymal tunic.

8.The apical suture that was
passed into the epididymal
lumen is now passed into the
lumen of the vas deferens
and secured.
9. Three other sutures are
then placed in between the
previous one and tied
posteriorly to anteriorly.

10.The muscularis and
adventitia of the vas deferens
are approximated to the
epididymal tunic, in a
circumferential fashion, with
eight to ten 9-0 sutures.

1. This technique differs
from the end-to-side
technique in that the
lumen is opened after
the sutures are
positioned in the
epididymal loop.

1. In the two-suture
modification, once the
dilated epididymal loop is
identified and the end of the
vas brought in close to the
epididymal loop, it is
secured to the tunic with a
single 9-0 suture, and two
parallel sutures are passed
into the tubule and left in
position.

 Post-op Care
 Similar to VasoVas
 Complications
 Infection
 Hematoma
 DVT
 Injury to testicular artery
 Results
 Very wide variation even with microsurgical techniques.

 Incision made over external ring at or near the pubic tubercle
 obviates the opening of the external oblique aponeurosis
 Dilated cremasteric veins ligated
 Spermatic cord opened
 spermatic veins in pampiniform plexus separated and ligated
 any dilated veins that accompany the vas deferens also ligated
Microscopic subinguinal approach
 Operating microscope used to dissect out and preserve the
testicular arteries and lymphatic vessels
 Some advocate delivering testicle into wound and ligating
external spermatic and gubernacular veins
 recurrence rate 0-2%, complication rate 1-5%

 Incision made over course of inguinal canal
 Ligation of cremasteric, deferential, and spermatic veins
performed with arterial preservation
 Microscope may be used as well

 Low abdominal incision above internal ring
 High ligation performed of entire spermatic pedicle (Palomo
procedure)
 testicular artery–sparing procedure performed by opening the
spermatic fascia to identify and preserve the artery
Laparoscopic-assisted retroperitoneal approach
 Artery may be spared
 lengthens the procedure
 higher recurrence rate (6-15%)
 due to inguinal and retroperitoneal collateral veins, failure to ligate fine
periarterial veins when testicular artery preserved
 20% incidence of hydroceles at 6 months if lymphatics not
preserved

Percutaneous Embolization
 Least invasive means of varicocele repair
 Internal spermatic vein accessed via cannulation
of femoral vein
 balloon and/or coil occlusion of varicocele
 failure rate of up to 15%
Antegrade sclerotherapy
 success rate is > 90%
 hydroceles are not a complication

Most methods of varicocelectomy result in
similar short-term results
Open microsurgical inguinal or subinguinal
techniques in adults shown to cause fewer
recurrences and complications
Given that efficacy all techniques is nearly
equivalent, attention must be paid to the
morbidity of the individual procedure and
expertise of the operating surgeon

 Check patient's semen 3-4 months after surgery if done for
infertility
 spermatogenesis requires approximately 72 days
 any effects from varicocele repair on semen parameters are
delayed

 Vasectomy after mass ligation varicocelectomy likely to result
in testicular atrophy
 Further supports artery-sparing technique

Hasan Farsi
K.A.University Hospital
King Faisal Specialist Hospital
Jeddah

 26y male with 1ry infertility of 3y.
 Examination: Bilateral normal testes, Bilateral grade
II varicocele.
 Semen x2 Azooepermia, Volume 2-3cc, normal
semen fructose
 FSH was normal.
 Bilateral inguinal varicocelectomy, testicular biopsy:
 Hypospermatogenisis

 18 months later one child
 Semen:
 Volume: 1.5 cc
 Conc.: 3 m/cc
 Motility: 25%

 10-15% general population
 40% 1ry infertility
 80% 2ry infertility

 Ambroïse Paré (1500–1590): a clinical problem
 Barfield, late 19th century: Relationship to infertility
 Lipshultz, 1979: Relationship to testicular atrophy that is
progressive with age
 Kass and Belman, 1987:significant increase in testicular volume
after varicocele repair in adolescents

 Sixty-four infertile male patients with varicocele :
 Varicocelectomy 31 cases
 No surgery 30 cases
 The mean follow-up duration was 76.2 months
 The pregnancy rate: (60%) VS (28%)
Int J Urol. 2002 Aug;9(8):455-61.

 146 men left varicocelectomy
 62 men refused surgery treated with tamoxiphene
 Followed up for at least 1 year
 Improvement in semen parameters:
 83.2% VS 32.3%
 Pregnancy within 1 year:
 62(46.6%) VS 8 (12.9%) (p<0.001).
Eur Urol. 2001 Mar;39(3):322-5.

 A meta-analysis was performed to evaluate both
randomized controlled trials and observational studies
using a new scoring system.
 Adjust and quantify for various potential sources of bias,
including selection bias, follow-up bias, confounding bias,
information or detection bias, and other types of bias, such
as misclassification
 Of 136 studies identified through the electronic and hand
search of references, only 17 studies met our inclusion
criteria

 Statistically significant improvement in:
 Concentration
 Motility
 Morphology
 CONCLUSIONS: Surgical varicocelectomy significantly
improves semen parameters in infertile men with palpable
varicocele and abnormal semen parameters.
Agarwal A, Department of Obstetrics Gynecology, Cleveland
Clinic Urology. 2007 Sep;70(3):532-8

 24 pts 63 intrauterine insemination cycles without varicocele
treatment.
 34 pts 101 intrauterine insemination cycles following
varicocelectomy.
 No statistically significant difference was noted in the mean post-wash
total motile sperm count in the treated and untreated groups.
 The pregnancy rate per cycle = 6.3 VS 11.8, p = 0.04
 Live birth rate per cycle =1.6 VS 11.8, p = 0.007
 Conclusion: A functional factor not measured on routine semen
analysis may affect pregnancy rates in this setting
Daitch JA. J Urol. 2001 May;165(5):1510-3

 68 infertile men
 Seminal plasma levels of two ROS and six antioxidants on the
day prior to varicocelectomy
 Same parameters were measured again 3 and 6 months post-
operatively.
 concluded that varicocelectomy reduces ROS levels and
increases antioxidant activity of seminal plasma from infertile
men with varicocele.
 Conclusion: Varicocelectomy reduces ROS levels and
increases antioxidant activity of seminal plasma from infertile
men with varicocele.
Mostafa T, Department of Andrology, Faculty of Medicine, Cairo
University Int J Androl. 2001 Oct;24(5):261-5.

 286 infertile men
 Physical examination, contact thermography, Doppler sonography,
and venography of both testes.
 88.8% bilateral
 Mean sperm concentration increased from 6.12 +/- 1.02 to 21.3 +/-
1.69 million/mL
 mean sperm motility from 16.81 +/- 1.51 to 35.90 +/- 1.41%
 mean sperm morphology from 9.75 +/- 0.85 to 16.92 +/- 1.17%.
 Pregnancy rate was 43.5%
 This may suggest that we should consider varicocele a bilateral
disease
Gat Y. Fertil Steril. 2004 Feb;81(2):424-9.

 The cost per delivery with ICSI was found to be
$89,091
 The cost per delivery after varicocelectomy was
only $26,268
 The average published U.S. delivery rate after one
attempt of ICSI was only 28%. whereas a 30%
delivery rate was obtained after varicocelectomy.
 CONCLUSIONS: Specific treatment of varicocele-
associated male factor infertility with surgical
varicocelectomy is more cost-effective than primary
treatment with assisted reproduction.
Schlegel PN. Urology. 1997 Jan;49(1):83-90

 Interestingly, the first study on the importance of
varicocelectomy to male infertility (Tulloch, 1952 ) reported
spontaneous pregnancy after varicocele repair in an
azoospermic man
Tulloch, W.STulloch, W.S Edinb. Med. J. 1952 , 59, 29–34.

 10 azoospermic patients
 2 pregnancies
Mehan DJ. Fertil Steril. 19761976 Jan;27(1):110-4.

 13 azo inguinal varicocelectomy
 Induction of spermatogenesis was achieved in 3 (23%) patients
 Two of them had hypospermatogenesis and one had
maturation arrest at spermatid stage
 No pregnancies by natural intercourse
Cakan M. Arch Androl. 2004 May-Jun;50(3):145-50

 14 Azo sclerotherapy
7/14 produced sperms
Sperm con 3.1 ± 1.2 × 106/mL
Mean sperm: 2.2 ± 1.9%
mean sperm normal morphology:
7.8 ± 2.2%
 2 pregnancies
Poulakis V. Asian J Androl. 2006 Sep;8(5):613-9.

 32 men with azoospermia
 Improved in 18/32:
 sperm concentration in the ejaculate 3.81±1.69 x 106/ml
 mean sperm motility: 1.20±3.62%
 mean sperm morphology: 8.30±2.64
 Nine pregnancies (26%)
 Four (12%) unassisted
 Five (15%) by ICSI
Gat Y. Human Reproduction 2005 20(4):1013-1017

 27 azoospermia microsurgical varicocelectomy
 Induction of spermatogenesis was achieved in nine men
(33.3%)
 Sperm conc 1.2 x 10(6)/mL to 8.9 x 10(6)/mL
 Motility 24% to 75.7%,
 One patient with maturation arrest established pregnancy
 Five relapsed into azoospermia 6 months after the recovery of
spermatogenesis
Pasqualotto FF, Fertil Steril. 2006 Mar;85(3):635-9.Pasqualotto FF, Fertil Steril. 2006 Mar;85(3):635-9.
Is the Effect Durable?

 17 azo microsur
 Spermatozoa in the ejacultae 47% (8/17)
 Only 35% (6/17) of them had motile sperm
 Mean time for appearance of spermatozoa in the ejaculates was 5
months (3 to 9 months).
Esteves SC. Int Braz J Urol. 2005 Nov-Dec;31(6):541-8.

 33 men with infertility & varicocele
 7 has coexisting genetic infertility:
 Abnormal karyotype in 4
 Y chromosome microdeletion in 3
 26 No defect
 Same semen parameters
 All had varicocelectomy
 54% VS 0% improvement
 CONCLUSIONS: From this early experience, men with
varicocele and genetic lesions appear to have a poorer
response to varicocele repair than men without coexisting
genetic lesions.

 What are the sonographic findings that could predict the outcome of
varicocele repair in the treatment of male infertility?
 107 patients with varicocele.
 CONCLUSIONS: The best preoperative sonographic parameters of
success of varicocele repair are:
 The presence of normal-sized testes
 Clinically palpable veins
 Bilateral varicocele
Donkol RH. J Ultrasound Med. 2007 May;26(5):593-9.

 grade 1--small (22 patients)
 grade 2--medium (44)
 grade 3--large (20)
 Sperm count, per cent motility, per cent tapered
forms were measured preoperatively and
postoperatively.
 Conclusion: infertile men with a large varicocele
have poorer preoperative semen quality but repair
of the large varicocele in those men results in
greater improvement than repair of a small or
medium sized varicocele.
Goldstein M.J Urol. 1993 Apr;149(4):769-71

 Preoperative FSH levels between men who did
(14.8 ± 3.1 IU/L) and did not (19.4 ± 3.8 IU/L) show
improvement in semen parameters after sclerotherapy were
not significantly different
Czplick M.Czplick M. Arch Androl. 1979;3(1):51-5

 Germinal Aplasia
 Maturation arrest at spermatocyte stage
 Hypospermatogenisis
 Maturation arrest at spermatid stage

 13 Azoospermic patients
 Age
 Preoperative sex hormones
 Unilaterl VS Bilateral
 Varicocele grade
 Hypospermatogenesis and late maturation arrest
Arch Androl. 2004 May-Jun;50(3):145-50
No association

Author Year No. of pts Tech. % of pts with sperms Pregnancy(%)
Czaplicki 1979 33 Micro 12(34%) 3 patients
Matthews 1998 22 Micro 12(55%) 3PTS
Kadioglu 2001 24 Micro 5(20.8%) ?
Kim 1999 28 Micro 12(43%) 2
Schlegel 2004 31 Micro 7(22%) Nil
Cakan 2004 13 Inguin 3(23%) Nil
Pasqualotto 2006 27 Micro 9(33.3) 1
Lee 2007 19 Micro 7(36.4%) 1
Esteves 2005 17 Micro 8(47%) 1 Spontan
4 ICSI
Gat 2005 32 Embo. 18(56.2%) 9(26%)
Poulakis 2006 14 Sclero 7(50) 2
Osmonov 2006 15 sclerot 8(53) all <0.1m/cc Nil
TOTAL 275 108 (39.27%)

 subclinical in 73 patients
 Clinical in 66 patients, based on palpation in addition to
ultrasonography.
 Conclusion: ligation of varicoceles detected using Doppler
ultrasonography, whether palpable or not, results in an
increase in sperm concentration and motility.
Pierik FH, Rotterdam, The Netherlands. Int J Androl. 1998 Oct;21(5):256-
60.

 76 underwent varicocele repair
 Improvement: Clinical VS subclinical:67% VS 41%
 But: Equal number were worse postoperatively and,
thus, mean sperm count was unchanged for the
group with subclinical varicocele
 Conclusion: The results of our study suggest that
subclinical varicocelectomy is of questionable
benefit.
Jarow JP North Carolina, USA. J Urol. 1996 Apr;155(4):1287-90

 350 patients:
 Ejaculated sperm
 Epididymal
 Testicular
CONCLUSION: The fertilizing ability of sperm in ICSI is highest with
normal ejaculated semen and lowest with sperm extracted from a
testicular biopsy in non-obstructive azoospermia.
Aboulghar M. Fertil Steril. 1997 Jul;68(1):108-11Aboulghar M. Fertil Steril. 1997 Jul;68(1):108-11

 Varicocele may cause any variation of severity in spermogram including
azoospermia.
 The treatment of varicocele may significantly improve spermatogenesis and
renew sperm production.
 Adequate treatment may spare the need for TESE as preparation for ICSI in
>30% of azoospermic patients.
 Since achievement of pregnancy in IVF units is higher when spermatogenesis is
better, the treatment of varicocele is an effective medical adjunct for IVF units
prior to the treatment.
 In men with spermatogenic failure, freshly ejaculated sperm are easier to use,
and fertilization ability in ICSI is higher with normal semen than with sperm
retrieved by TESE

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