The Effects of Varicocelectomy on Sperm DNA Fragmentation and Conventional Semen Parameters in Men with Severe Oligoasthenoteratozoospermia: A Prospective Study

Abstract

Background:

The dilation and torsion of testicular veins in the plexus pampiniformis causes Varicocele, which is a surgically repairable cause of male infertility. This study assessed the impact of varicocelectomy on semen characteristics, total motile sperm count (TMSC) and sperm DNA integrity in patients with severe oligoasthenoteratozoospermia (OAT).

Materials and Methods:

In this prospective study, semen samples of 360 men with severe OAT who underwent varicocelectomy according to World Health Organization (WHO) criteria 2021 were studied (pre-operatively and at 6, 12, and 18 months post-operatively).

Results:

The average age of our patients was 38.5 years. The mean spermatozoa concentration was found to be 1.60 ± 0.83 million/ml pre-operatively, while the mean post-operative concentration was 5.17 ± 1.23 million/ml at 6 months, 8.32 ± 0.98 million/ml at 12 months, and 13.51 ± 1.48 million/ml at 18 months (P<0.0001). The mean percentage of A+B motile spermatozoa was 2.92 ± 1.17% pre-operatively, 6.10 ± 1.51% at six months, 9.58 ± 1.49% at 12 months and 13.92 ± 1.88% at 18 months postoperatively (P<0.0001). The mean Modified David’s morphology score was 3.80 ± 1.43% pre-operatively, 5.95 ± 1.23% at 6 months, 7.94 ± 1.18% at 12 months, and 10.82 ± 1.91% at 18 months post-operatively (P<0.0001). The mean of total motile sperm count (TMSC) was statistically improved after varicocelectomy (P<0.001). The mean of DNA fragmentation index (DFI) of the spermatozoa was 31.40 ± 0.52% pre-operatively, and post-operatively at 28.20 ± 0.32% at 6 months, 25.90 ± 0.31% at 12 months and 20.50 ± 0.40% at 18 months (P<0.001).

Conclusion:

Varicocelectomy was associated with significant improvement of sperm parameters and DNA fragmentation resulting in significant improvement of spermatogenesis quality. We believe that universalization in the routinely used sperm dispersion chromatin (SDC) test could be beneficial in the treatment of infertility.

Introduction

Varicocele is a vascular disease characterized by the abnormal dilatation of the pampiniform plexus veins after a renospermatic venous reflux by valvular insufficiency. It is the most frequent and reversible cause of male hypofertility (1). It is a common male pathology with an incidence of up to 22% of men in the general population. This incidence is even higher in the infertile male population and is estimated to be 40% when there is an alteration in the spermogram (2). Nowadays, with advances in medical imaging, it is found in a quarter to a third of infertile men. It is a significant factor in infertility, and spermatic vein ligation is generally considered the treatment of choice (3, 4). In recent studies, it was found that about 85% of cases of varicocele are bilateral and 15% of cases are unilateral, suggesting a progressive impairment in the male fertile potential caused by varicocele (5). While other study have indicated improvement in the semen parameters after varicocelectomy (6), some other research reveals no benefit (7).

There are divergent opinions on the subject of whether a varicocelectomy enhances fertility. The etiology of varicocele is thought to be multi‑factorial. Male infertility due to varicocele can be carried on by several different causes, including scrotal heat, hormonal imbalances, testicular hypoperfusion, hypoxia, and the backflow of toxic metabolites (8). Continuous exposure to high temperatures impairs spermatogenesis, semen quality, and testicular volume as well as increasing the amount of immature sperm in the ejaculate (9). The Best Policies Practice Groups of the American Urological Association and the American Society for Reproductive Medicine have recognized that repair of varicocele is indicated for infertile men with palpable lesions and one or more abnormal semen parameters (10, 11). Varicocele could affect the concentration, motility, morphology, total motile sperm count (TMSC) index and DNA integrity of spermatozoa (12).

The quality of sperm chromatin is a significant factor in maintaining male fertility potential. Sperm DNA provides half of the genetic material to the embryo produced by fertilizing. Many factors such as drugs, cigarette smoking, genital tract inflammation, hormonal factors, varicocele, and testicular hyperthermia are among the main reasons for DNA damage. No study has been as contentious as the effect of varicocelectomy on male factor infertility in Morocco. The purpose of this prospective study is to evaluate the impact of varicocele ligation on sperm characteristics, and sperm DNA fragmentation as well as examine the level of TMSC in semen samples collected before and after 6^th, 12^th and 18^th months from infertile men with varicocele associated with severe oligo-asthenoteratozoospermia admitted in our centre of reproduction in Mohammed VI University Hospital, Center of Oujda, Morocco.

Materials and Methods

Patient recruitment

This prospective study was carried out in the Assisted Reproduction Unit of Mohammed VI University Hospital Center (Oujda, Morocco), the first Unit established in the eastern region of Morocco. The Centre provides infertility services for men from Oujda and other provinces of the region. It was an observational and prospective study conducted with patients followed up from December 2020 to September 2022 with the inclusion of 360 severe oligo-astheno-teratospermic (OAT) patients operated for varicocele. The age of patients recruited is between 28 and 57 years (mean 38.5 ± 1.6).

Patients met the criteria of a palpable varicocele on examination, confirmed on Doppler scrotal ultrasound in different varicocele grades mostly in grades 1 and 3, and were referred to our assisted reproduction centre by their urologist after varicocele treatment for a checkup every 6 months to evaluate the sperm parameters. To reduce possible inter-laboratory variations, we included only the preoperative (before varicocelectomy) and postoperative semen analyses (6, 12 and 18 months after surgery) conducted in the same laboratory for data analysis. The evaluation of the results of the varicocele cure made after a follow-up of at least six months was based on the spermogram by comparing the pre and post-operative sperm parameters.

Semen sample analysis

Semen analysis was carried out in accordance with WHO recommendations from the 6^th edition (13). Sperm volume, concentration, motility, and morphology in the semen were examined. A clean sterile plastic container confirmed to be non-toxic for spermatozoa was given to each participant to produce semen samples by masturbation (after 3 days of sexual abstinence). To minimize temperature fluctuations and control the time between semen sample collection and analysis, samples were collected in our Unit. Macroscopic analysis of the sperm was performed with the observation of liquefaction time, viscosity, semen volume, colour, and pH. The study of the sperm was undertaken only with all the guarantees that the collection was done without loss and in the good conditions required for this purpose.

First, a Pasteur pipette was used to homogenize the semen samples and the evaluation of concentration and motility of spermatozoa parameters was conducted using the Computer Assisted Sperm Analyzer (SCA, MICROPTIC, Barcelona, Spain). For each measurement, a 2.5 μl aliquot of sperm was loaded into a standard four-chamber slide (Leja, NL, Nieuw-Vennep The Netherlands). The spermatozoa fast and slow progressive motility were counted (A+B), followed by the nonprogressive motile (C) and non-motile spermatozoa (D). Sperm concentration and sperm motility were determined using 10× magnifications.

The evaluation of the spermatozoa morphology was made based on Modified David criteria and was evaluated using the Diff-Quik kit (Dade Behring AG, Switzerland) contains one stain fixative and two stains (A, B). Morphological assessment was performed with a Nikon microscope using an oil immersion (Nikon Company, Japan). A minimum of 100 sperm cells was counted. Strict scoring criteria were used to classify men as having normal or abnormal morphology according to David’s modified classification.

DNA fragmentation assessment

DNA fragmentation was assessed by Sperm Dispersion Chromatin (SCD) tests. In the absence of massive sperm DNA breakage and following acid denaturation and removal of nuclear proteins, dispersed DNA loops produce a characteristic halo. Sperm fragmented DNA does not develop such a halo, or it is small. DNA fragmentation test was performed using the SDC method by Spermfunc® DNA kit at BRED Life Science Technology Inc., China. The agarose was placed at a temperature of 90-100°C for 5 minutes and heated at 37°C for 5 minutes. Then, the semen was added to the agarose and mixed well. The suspension was poured on agarose-coated slides and covered with a 20×20 mm cover glass. The slides cooled at 4°C for 5 minutes, then were slowly opened. They were then incubated in a denatured solution at 22°C for 7 minutes and lysis solution at room temperature for 25 minutes. After washing with H₂O for 5 minutes, they were dehydrated with graded ethanol at 70, 90, and 100% for 2 minutes per concentration. The slides were dried and stained with Wright’s solution for 25 minutes. This is followed by observation via a light microscope based on various halo images, namely large, medium, small, no halo, and degraded sperms. The big and medium halos were classified as un-fragmented DNA, while others as fragmented DNA. Observations were made by two observers through the determination of the fragmented and un-fragmented DNA randomly in 500 sperm as a DNA fragmentation index (DFI) and then calculated the DFI as:

DFI (%)=100×(number of SPZ with fragmented DNA/ total number of SPZ)

Total motile sperm count analysis

Using a two-layered density gradient centrifugation technique, sperm samples were prepared. (50 and 90% Isolate, Irvine Scientific, Santa Ana, USA). Male-factor infertility was not strictly defined but rather was assessed by analyzing the number of motile sperm in the ejaculate. TMSC in the ejaculate was calculated using the formula:

TMSC=semen volume (ml)×sperm concentration (millions per ml)×percentage motility divided by 100 (%).

In addition, the patients were further divided into 4 groups according to the TMC based on the WHO reference as less than 0.5×10⁶, 0.5-1×10⁶, 1-2×10⁶ and greater than 2×10⁶.

Ethical approval

The study was approved by the Research Ethics Review Committee of the Faculty of Medicine and Pharmacy of Oujda (02-2023). All of the subjects enrolled on the study gave written formal consent to participate. The Subjects were informed of the scientific nature of the study.

Statistical analysis

The data were analyzed using the IBM Statistical Package for Social Sciences 24 (IBM Corp., Armonk, NY, USA). Summaries for continuous variables were expressed as mean ± standard deviation (SD). Categorical variables were expressed as numbers and percentages (%). Frequencies were expressed as percentages by comparison with mean values among the two groups, control vs. (6, 12 and 18 months), respectively, using paired t test analysis. The normal distribution of the data was tested using Kolmogorov-Smirnov and Shapiro- Wilk tests. Differences between the pre and postvaricocelectomy semen parameters were estimated by analysis of variance (ANOVA) to compare pre-operative, 6 month, 12 month and 18 months post-operative values of different sperm parameters. The P<0.05 is considered statistically significant.

Results

We collected a total of 360 records of patients over 22 months. The minimum duration of the marriage was 12 months. The average age of the men was 38.5 ± 1.6 years, ranging from 28 years to 57 years. In this study, 72.3% of patients had primary infertility while 27.7% had secondary infertility. Varicocele was bilateral in 72.8% of patients and found only at left in 15.6% of cases. Only one patient (4.8%) had a varicocele found only on the right. The motif for consultation in our series was mainly infertile. The most frequent clinical grades of varicocele on clinical examination were grade 2 and grade 3.

Effects of varicocelectomy on semen volume, sperm concentration and sperm motility

Sperm counts were significantly increased by six, twelve and eighteen months following surgical repairs of varicocelectomy. The changes in volume and concentration of spermatozoa at six, twelve and eighteen months after repair are summarized in Figure 1.

In pre-operative, the mean semen volume was 2.52 ± 0.85 ml (Fig .1A), and the spermatozoa concentration was 0.01 to 3.5 M/ml with a mean value of 1.60 ± 0.83 M/ml (Fig .1B). The mean percentage of A+B progressive motile spermatozoa was 2.92% ± 1.17, C motile spermatozoa were 8.37% ± 3.05 and D non-motile spermatozoa was 88.70% ± 3.81 (Fig .1C).

Fig 1.

Semen volume, spermatozoa concentration and motility findings. A. Variation of mean semen volumes of pre- and post-operative (OP) specimens. B. Variation of mean spermatozoa concentration of preand post-operative specimens. C. Variation of mean A+B (P<0.0001), C (P>0.0001) and D (P<0.0001) motile spermatozoa percentages of pre- and post-operative. Ns; Not significant and ****; P<0.0001.

At post-operative six months of varicocele, the mean semen volume was 2.63 ± 0.60 ml (Fig .1A), The range of the mean spermatozoa concentrations was 1.4 to 8.5 M/ ml, with a mean value of 5.17 ± 1.23 M/ml. (Fig .1B), the mean percentage of A+B motile spermatozoa was 6.10% ± 1.51, C motile spermatozoa were 13.1% ± 3.13 and the non-motile spermatozoa (D) was 80.79% ± 3.86 (Fig .1C).

At post-operative twelve months of the varicocele, the mean semen volume was 2.74 ± 0.49 ml (Fig .1A), the mean spermatozoa concentrations were between 5.4 and 10.7 M/ml with a mean value of 8.32 ± 0.98 M/ml (Fig .1B), the mean percentage of A+B motile spermatozoa was 9.58 ± 1.49%, C motile spermatozoa were 18.14% ± 3.03 and type D was 72.27% ± 4.10 (Fig .1C).

At post-operative eighteen months of varicocele, the mean semen volume was 3.38 ± 0.51 ml (Fig .1A), The range of the mean spermatozoa concentrations was 9.07 to 17.8 M/ ml, and the mean was 13.51 ± 1.48 M/ml (Fig .1B), the mean percentage of A+B motile spermatozoa was 13.92% ± 1.88, C motile spermatozoa were 23.79% ± 3.62 and D non-motile spermatozoa was 62.28% ± 4.71 (Fig .1C).

The mean spermatozoa concentration was statistically significantly increased in the post-operative samples compared to the pre-operative samples, no difference could be identified in semen volumes of the six and twelve months but significantly increased in eighteen month’s group (P<0.0001). A comparison of the data from all groups (pre-operative and postoperative 6 months, 12 months and 18 months) revealed a statistically significant difference between A+B motility percentages (P<0.0001), C motility (P<0.0001) and D motility (P<0.0001).

Effects of varicocelectomy on Modified David’s morphology

In this study, the morphological analysis of the spermatozoa was based on modified David’s classifications using the Diff-Quik kit.

The mean normal typical percentage of spermatozoa was recorded as 3.80% ± 1.43 before the varicocele operation (Fig .2A).

Fig 2.

Morphology findings of the spermatozoa. A. Variation of mean typical morphology of spermatozoa in pre and post-operative (OP) samples, B. Variation of mean abnormal morphology of spermatozoa including head (P>0.05), acrosome (P>0.05), neck (P<0.05), tail (P<0.0001) and mixed (P<0.001) abnormalities in pre- and post-operative specimens in time. ****; P<0.0001.

In pre-operative, the mean spermatozoa percentage with head defects was 30.32 ± 7.13%, acrosome abnormalities were 24.35 ± 4.57%, spermatozoa with a broken neck or cytoplasmic waste in the neck region and neck abnormality was 24.75 ± 3.85%, tail abnormalities were 9.54 ± 2.30% and also spermatozoa with mixed abnormalities was 7.17 ± 4.11% (Fig .2B).

For post-operative 6 months, typical morphology was 5.95 ± 1.23% (Fig .2A), head abnormality was 28.62 ± 3.25%, acrosome abnormality was 23.06 ± 4.53%, neck abnormality was 23.42 ± 3.91%, tail abnormality was 8.41 ± 2.36% and mixed abnormality was 5.97 ± 3.11% (Fig .2B).

At 12 months after varicocelectomy, normal spermatozoa morphology was 7.94 ± 1.18% (Fig .2A), the head abnormality was 20.06 ± 3.39%, acrosome defect was 20.95 ± 4.22%, neck abnormality was 20.24 ± 4.12%, the tail abnormality was 6.27 ± 1.63% and mixed defects were 4.61 ± 2.58% (Fig .2B).

At 18 months, the typical morphology of spermatozoa was 10.82 ± 1.91% (Fig .2A), head defect was 22.83 ± 3.27%, acrosome abnormality was 17.94 ± 3.77%, neck abnormality was 16.65 ± 3.50%, tail defect was 4.68 ± 1.32% and mixed defects were 3.24 ± 2% (Fig .2B).

Table 1.

Variation of TMSC between pre-operative and post-operative varicocelectomy

TMSC	Pre-operative	Post-operative			P value
	Initial	Change by 6 months	Change by 12 months	Change by 18 months
Total group	0.023 M ± 0.014	0.41 M ± 0.29	1.19 M ± 0.37	2.14 M ± 0.49	<0.0001
<0.5 million motile sperm (IVF/ICSI)	0.023 M ± 0.014	0.12 M ± 0.10	0.15 M ± 0.1	_	Ns
0.5-1 million motile sperm (IIU)	_	0.69 M ± 0.09	0.81 M ± 0.09	0.9 M ± 0.001	<0.0001
1-2 million motile sperm (IIU)	_	1.1 M ± 0.002	1.47 M ± 0.19	1.67 M ± 0.21	<0.0001
Greater than 2 million motile sperm (natural)	_	_	_	2.64 M ± 0.42	_

Data are presented as means ± SD. TMSC; Total motile sperm count, IVF; In vitro fertilization, ICSI ; Intracytoplasmic sperm injection, SD; Standard deviation, M; Millions, and Ns; Non-significant.

The head defects of the spermatozoa included large, small, round, pyriform, amorphous and pinhead. Acrosomal abnormalities were observed in the study such as large, small or vacuolated acrosomes. The tail abnormalities of the spermatozoa specimens were assessed regarding tail length, thickness, count and shape. Spermatozoa specimens often had mixed abnormalities, referring to the presence of multiple abnormalities of the head, acrosome or tail in one spermatozoon (Fig .3).

Fig 3.

Morphological analysis of the spermatozoa was based on modified David’s exact criteria. A. Pre-operative spermatozoa morphology: pyriform and pinhead, small tail coiled around the head, spermatozoa with round and small acrosome. B. Post-operative spermatozoa morphology at 6 months: thind head and microcephaly, vacuoled acrosome, abnormal cytoplasm in the neck, small and coiled tail spermatozoa. C. Postoperative spermatozoa morphology at 12 months: small and curled tail duplicate tail, abnormal head (angulation). D. Post-operative spermatozoa with head defects at 18 months: pyriform head, irregular tail (Diff-Quik kit, 40×, scale bar: 20 μm).

Effects of varicocelectomy on total motile sperm count

The mean TMSC of 360 patients was 0.02 ± 0.01 M before surgery and 0.41 ± 0.29 M at six months, 1.19 ± 0.37 M at 12 months, 2.14 ± 0.49 M at 18 months after surgery (Fig .4).

Fig 4.

Variation of pre and post-operative mean of TMSC of the patients. TMSC; Total motile sperm count, ***; P>0.001, and ****; P<0.0001.

Table 1 shows the TMSC distribution of 65 patients according to the TMSC classification reference values for the choice of the appropriate assisted reproductive technology (ART) technique for each couple.

DNA fragmentation index of the spermatozoa

The mean DFI of 200 spermatozoa specimens was 31.40 ± 0.52% before surgery and 28.20 ± 0.32% at six months, 25.90 ± 0.31% at 12 months, 20.50 ± 0.40% at 18 months after surgery (P<0.001, Fig .5). A comparison of DFIs between the pre and post-operative patients reveals a significant difference (P<0.001), and also a significant difference is noted between the DFIs at 6, 12, and 18 months (P<0.001).

Fig 5.

Distribution of pre- and post-operative mean DNA fragmentation index of the patients. ****; P<0.001.

Discussion

The andrologist’s goal for the infertile male is to improve the quality of sperm sufficiently to enable the couple to conceive using the least invasive and expensive approach possible. Varicocele is known as one of the most important causes of male infertility. One of the primary causes of varicocele repair is male factor subfertility based on abnormal semen characteristics (14). Numerous research has shown that varicocele repair has a positive impact on male reproduction with an improvement in semen quality. Despite individual variations, varicocele is known to negatively impact spermatozoa morphology, concentration and motility, and may occasionally adversely impact all spermatozoa parameters (15). Instead, varicocelectomy gives a couple experiencing male factor infertility the chance to use a less invasive and expensive reproductive modality in the hopes of improving or preventing further deterioration of seminal parameters. Several works have mentioned the harmful influence of varicocele on sperm parameters (16). The process of spermatogenesis is frequently disturbed by varicocele. Subfertile males who have varicocele experiences aberrant sperm quality, such as a low sperm count, impaired sperm motility, and a high percentage of aberrant sperm forms. Most reports indicate that after spermatic vein ligation, sperm quality improves in about two-thirds of varicocele patients (6). Varicoceles remains the most prevalent treatable cause of male factor infertility, and numerous studies have associated their presence with infertility (17). Since there was no improvement in sperm parameters 3 months after the varicocele treatment, we chose to evaluate these parameters every six months in parallel with the intake of antioxidants. There are few studies in the literature on the effect of varicocelectomy on sperm characteristics and TMSC indices evaluated in severe oligoasthenospermia, especially in Morocco.

The American Society for Reproductive Medicine’s Practice Committee advised waiting one year for semen characteristics to improve, but as far as we could tell there are no studies to evaluate the improvement of spermatic parameters after more than 12 months, which is the objective of our study (18). This study now indicates that the outcome of the repair was evaluated as early as 6 months and then decide if the couple should proceed with the use of an ART.

Varicocelectomy improved sperm parameters as reported in several other series. After varicocelectomy, seminal parameter improvement is generally reported as an increase in volume, motility, concentration, morphology, and TMSC based on pre and postoperative semen analyses. Afsin et al. (19) reported that a preoperative mean spermatozoa concentration of 45.25 M/ ml increased to 48.85 M/ml, 51.72 million/ml, 49.63 M/ ml at 3, 6 and 12 months post-operatively respectively. However, the mean of A+B motile spermatozoa increased from 35.5% pre-operatively to 42.65, 43.02, and 44.05 at 6 months, 12 months and 18 months respectively. According to Morini et al. (20), the mean spermatozoa concentration increased from 46.96 M/ml pre-operatively to 52.33 M/ml after surgery, while the percentage of A+B motile spermatozoa improved from 28.69 to 37.36%. Similarly, in a study by Machen et al. (21) the mean sperm count significantly increased at 3 to 6 months after varicocelectomy.

In this study, the mean spermatozoa concentration of 360 patients with severe Oligoasthenoteratospermia was 1.60 M/ml pre-operatively, and 5.17 M/ml at six months, 8.32 million/ml at 12 months and 13.51 M/ml at 18 months, post-operatively. The mean A+B motile spermatozoa rate was 2.92% pre-operatively, and 6.10% at six months, 9.58% at 12 months and 13.92% at 18 months, post-operatively. This was confirmed by the meta-analysis of Agarwal et al. (22), who underlined a net increase in sperm concentration varying from 9.7 million/mL to 12 M/mL, depending on the technique used (high ligation or microsurgery), an increase in motility of 9.9 and 11.7% reciprocally, and a decrease in teratozoospermia of 3%. Our findings revealed an increase in spermatozoa concentration, motility and morphology in pre and post-operative which are parallel with those of Morini et al. (20) and with Afsin et al. (19). In our study, there was a significant increase in normal sperm morphology and a significant decrease in abnormal morphology after varicocelectomy. Morini et al. (20) also noted that in 30 individuals with varicocele, the mean percentage of spermatozoa with a normal morphology increased from 3.07% prior to surgery to 6.22% three months later. Afsin et al. (19) show that the mean rate of spermatozoa in a normal morphology was 3.15% before the operation, and increased to 3.20, 2.97 and 3.27% at three months, six months and 12 months post-operation in 40 patients with varicocele. However, Kibar et al. (23) showed that varicocele surgery had minimal to no impact on morphological defects in terms of spermatozoa concentration or motility. While the average percentage of spermatozoa with normal morphology was 3.15% before surgery, it was 3.14% post-surgery (3^rd, 6^th and 12^th months). The morphological structure of spermatozoa was significantly affected by varicocele surgery, according to Kibar’s findings. Similarly, Leung et al. (24) reported a significant improvement in the mean sperm concentration (from 12 to 23 million/mL), motility (from 26 to 32%), and normal morphology (from 5 to 6%) after varicocelectomy. We believe that further studies with larger numbers of patients need to be carried out if a consensus is to be reached on varicocele surgery.

A different way to evaluate sperm quality is the calculation of the TMSC, which is obtained by multiplying the volume of the ejaculate by the sperm concentration and the proportion of A and B motile sperm divided by 100. The sperm parameter morphology is not taken into account in this calculation. TMSC is used to assist in the decision of whether to treat with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) and has been demonstrated to possess the best reproducibility of all sperm parameters. For those patients with TMSC<0.5 Million motile sperm, we recommend FIV/ICSI. For patients with TMSC between 0.5-1 Million or between 1-2 Million motile sperm, we recommended referral for IUI. For those who have TMSC greater than 2 Million, attempt natural conception. In fact, many men with a low initial TMC (less than 0.5 million) had improved to a moderately low TMC (TMC 0.5 to 1×10⁶) or normal TMC (TMC greater than 1×10⁶) after varicocele repair (25). Many of these men who initially would likely have required intracytoplasmic sperm injection to conceive may potentially be able to take advantage of less invasive options [like intra-uterine insemination (IUI)]. For severe oligoasthenospermia patients, Some authors report significant improvement in both TMSC and pregnancy rates following varicocelectomy. Varicocelectomy may upgrade the quality of the semen parameters, which may allow the couple to use the least invasive IUI instead of IVF (26).

There are several studies that measured the DNA defects in accordance with the DFI, and concluded that the percentage of DFI is significantly higher in infertile males with normal spermatozoa parameters than in fertile males (27). It has been reported that varicocele reduces DFI in sterile men with varicocele and also has a positive effect on spermatogenesis. Sperm DFI assessment has been suggested as a complement to conventional semen analysis in the context of varicocele (28). The statistically significant improvement in DNA fragmentation indexes was observed between pre- and post-varicocele surgery, which is in line with Birowo et al. (29). Our examinations of spermatozoa count, motility, and morphology parameters, as well as DNA fragmentation, were conducted in patients with pre- and post-varicocele surgery. After surgery, we observed a significant improvement in the level of DNA fragmentation, as well as an increase in spermatozoa concentration, motility, and morphology. Combined with the results of previous studies, surgery may be recommended for varicocele patients with high DNA fragmentation in their semen samples.

Conclusion

Our examinations of spermatozoa count, motility, morphology, and TMSC in patients before and after varicocele surgery are a result, Sperm concentration, motility, morphology, TMSC and DNA fragmentation were reported to have been significantly improved after surgery. Combined with the results of previous papers and ours, surgery may be recommended for varicocele patients. Sperm parameters improve 6 months after varicocelectomy, as shown in the results of this study. Clinicians should be able to quickly determine if the varicocelectomy was successful and plan for alternative medications to manage infertility if necessary. Considering our initial results, we made an effort to increase the study population and examine pregnancy data after 18 months of varicocelectomy in severe oligoasthenospermia. In our opinion, randomized controlled studies that involve more patients are necessary to reduce the debate on the necessity of varicocele surgery.

Authors’ Contributions

C.R.; Writing-original draft, Conceptualization, Methodology, Software, Validation, Formal analysis, and Visualization. I.B.; Resources, Data curation, and Software. A.E.M.; Resources, Data curation, and Software. S.E.A; Visualization, Writing, and Statistical analysis. S.M.; Visualization, Writing-review, Editing, Supervision, and Investigation. H.T.; Writing-review and Editing. A.B., A.M.; Writing-review, Editing, and Visualization. M.C.; Project administration, Visualization, Writing-review, Editing, Resources, Conceptualization, Methodology, and Validation. All the authors have read and agreed to the final manuscript.