Case report of testicular failure and azoospermia after antegrade embolization of varicocele: A rare complication

Abstract

Introduction

Varicocele is a common condition affecting males of reproductive age and accounting for the most frequent cause of secondary infertility in males.

Presentation

A young male presented with second infertility and bilateral varicoceles and underwent antegrade angioembolization. He developed testicular ischemia and testicular failure with new onset hypogonadism and cryptozoospermia.

Conclusion

Antegrade embolization is a valid option in patients with varicoceles but has its own unique risks of complications.

Highlights

• •Angioembolization use for varicocele becomes popular option for the past years.
• •Surgical intervention and angioembolization technique can improve semen parameters in infertile men.
• •Angioembolization have its unique risk compared to surgery.
• •Angioembolization of varicocele should be considered as alternative option after microscopic surgery.

1. Introduction

Varicocele is a common cause of male infertility and can cause other andrological diseases, such as hypogonadism, scrotal pain, and ipsilateral testicular atrophy. Varicoceles are found in 15 % of normal males [1], [2]. The incidence of varicoceles in men with primary infertility is around 35–44 %, whereas the incidence in those with secondary infertility is up to 81 % [[1], [2], [3], [4], [5], [6]]. Varicoceles are classified into the following based on a clinical exam [[3], [4], [5]]: subclinical, not detectable by physical exam and seen only by ultrasound (US); Grade 1, palpable with Valsalva maneuver; Grade 2, palpable at rest; and Grade 3, visible and palpable at rest. The use of scrotal US is indicated in certain conditions if a clinical exam is not conclusive and the varicocele recurs after surgery [3], [7]. Interventional radiology techniques (e.g., sclerotherapy and embolization) are minimally invasive approaches for varicocele treatment, with results comparable to microscopic surgical ligation in terms of semen parameters, including total sperm motile count improvement, but they have unique disadvantages compared to microscopic surgery, including failure of embolization, radiation, and in rare cases, migration of coils [[8], [9], [10], [11]]. To my knowledge, this is the first case to be reported with this complication after antegrade embolization. This case report has been reported in line with Surgical Case Report criteria [12].

2. Case presentation

The patient was a middle-aged male not known to have a chronic disease. He presented with a history of second infertility for 7 years. He fathered one child, 8 years old, in a normal pregnancy. He visited an infertility clinic for second infertility, and the initial investigation showed oligoasthenoteratospermia, which decreases sperm count and motility and increases abnormal forms. Hormonal profile within normal (see Table 1, Table 2). His clinical exam revealed normal-sized testes with bilateral varicocele Grade 1 on the right side and Grades 2–3 on the left side. A scrotal US was performed (Fig. 1), which confirmed the clinical exam finding. He was given the option of microscopic varicocele ligation or angioembolization and decided to undergo angioembolization. The procedure was performed uneventfully in mid-2022 in a private clinic through an antegrade sclerotherapy injection using medical glue (cyanoacrylate glue). One week after the procedure, the patient went to the emergency department complaining of bilateral testicular pain and swelling. A Doppler US was performed and showed decreased vascularity with suspicious focal ischemia and heterogeneity in both testes (Fig. 2). He was given nonsteroidal anti-inflammatory drugs and pain medication. The pain began to subside afterward.

Table 1.

Semen analysis before and after embolization.

Result	Before	4 months after
Sperm count (million/ML)	18 million/ML	Few non-motile sperm seen only after centrifuge
Total motility	28 %	N/A
Progressive motility	15 %	N/A
Morphology	2 %	N/A

Table 2.

Hormonal profile.

Result	Before	After
FSH	2.75 mIU/ML	60 mIU/ML
LH	1.8 mIU/ML	20 mIU/ML
Total testosterone	12.9 nmol/L	7.2 nmol/L

FSH: follicular stimulating hormone.

LH: luteinizing hormone.

Fig. 1.

Testicular size and left varicocele seen in ultrasound.

Fig. 2.

One week after procedure (hypoechoic area with decrease vascularity … more in right side).

The patient presented to our clinic for the first time 4 months after angioembolization with a semen analysis showing azoospermia. At that time, pain was mild, and an examination showed that testicular size had decreased bilaterally around 5–7 ML each. The testes were tender to touch, and the patient also complained of hypogonadal symptoms, which included decreased libido and erectile dysfunction. We conducted a full infertility workup. The repeated semen analysis showed cryptozoospermia (very low sperm count), and his hormonal profile reflected primary testicular failure, with a follicular stimulating hormone level of 60, a luteinizing hormone level of 35, and low testosterone (see Table 2). A scrotum US was performed and showed bilateral testicular atrophy, with a maximum volume of around 7 ML (Fig. 3), and an abdominal z-ray was also done to check the coils, which were in place (Fig. 4). Sperm freezing was recommended, as testicular function was clearly declining. The patient had some samples frozen. The option of microscopic testicular sperm extraction, followed by testosterone replacement therapy, was discussed, but the patient refused, as he wished to start the testosterone replacement therapy.

Fig. 3.

Loss of testicular size 4 months after embolization.

Fig. 4.

Kidney, ureter, and bladder (KUB) X-ray showing coils in place.

3. Discussion

Angioembolization is an effective method for treating varicoceles, but has its own unique risks. For most cases, it is considered a valid option. However, higher recurrence rates have been reported compared to microscopic varicocelectomy [11], although both have had comparable recurrence and success rates in recent studies [9], [10], [11]. Both microscopic surgery and angioembolization improve semen parameters in infertile men [9]. The benefits of no general anesthesia and a short procedure time are other reasons for adopting this technique. In my opinion, it is a good alternative to microscopic varicocele ligation for patients labeled morbidly obese, at high risk for using anesthesia or anticoagulants, and at high risk of recurrent varicocele after surgery.

4. Conclusion

Angioembolization can have unique risks regarding the material used for embolization, and it introduces more radiation to the patient compared to standard microscopic varicocelectomy. It can be useful in the recurrence of varicoceles after microscopic surgery or in certain patients who are not fit for surgery.

Informed consent

I have written and verbal consent from the patient himself.

Ethical approval

The case report is exempted from ethical approval committee as long there is consent from the patient him self and the report does not contain any personal information that could lead to the identification of the patient.

Funding

No source of funding.

Author contribution

I'm the only author.

Guarantor

Raed Alasmi.

Research registration number

Not applicable.

Declaration of competing interest

No conflict of interest.