Effect of varicocoelectomy on seminal fluid parameters

Abstract

Background

Infertility can be a source of anxiety and marital disharmony to a couple. The male factor traditionally contributes 40%. Varicocoeles are a significant cause of male infertility.

Aim

To assess the effect of varicocoelectomy on seminal fluid analysis parameters in sub-fertile males.

Methodology

This was a prospective study of fifty four patients who presented with infertility to the urology clinic of University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria between January 2015. and January 2016 . Those who had clinically palpable varicocoeles as the only suspected cause of their infertility were enrolled. The varicocoeles were classified into right, left or bilateral and graded into grades 1, 2 and 3 using Dubins criteria. Each patient had two semen analyses done two weeks apart and underwent a bilateral varicocoelectomy via the inguinal approach. Seminal fluid analyses were done post operatively at four and six months.

Results

Of the 54 patients that underwent varicocoelectomy, 11 (20.4%) had azoospermia, 28 (51.9%) had oligospermia and 15 (27.8%) had counts greater than 20 million but less than 40 million. Following varicocoelectomy there was a statistically significant increase in overall motility (p=0.000), morphology (p=0.000), density (p=0.000) and semen volume (p=0.004). Assessing only oligospermic patients there was no significant improvement in morphology (p=0.160). Azoospermic patients showed statistically significant improvement in all parameters though the values were well below those accepted for spontaneous conception.

Conclusion

Varicocoelectomy improves semen parameters in patients with varicocoele induced semen anomalies; it may provide an option for retrieving viable semen for patients with varicocoele induced azoospermia.

Introduction

In sub-Saharan Africa, the need to have children to bequeath wealth and property remains a driving force for marriages1. The absence of children is a major source of anxiety and depression to the affected couple2.

Fertility is the natural capacity to produce offspring while infertility is defined as one year of unwanted non-conception with unprotected intercourse in the fertile phase of the maternal cycle3. Infertility is noted to be highest ‘ironically’ in countries with high fertility rates (fig 1.)

The term varicocoele refers to a condition manifested by abnormal dilation of veins of the spermatic cord, caused by incompetent valves of the internal spermatic veins and resulting in impaired drainage of blood into the spermatic cord veins when the patient assumes an upright position4.

It is the most common cause of male infertility worldwide5 and has been found in fifteen percent of normal men and forty percent of males who present with primary infertility and is as high as seventy percent in men who present with secondary infertility5.

Varicocoeles are an important cause of male infertility worldwide and have been shown to be significant in Sub-Saharan Africa6,7. The postulated mechanisms by which varicocoeles affect fertility include elevated temperature, adrenal hormone reflux, gonadotoxic metabolite reflux, altered testicular blood flow, antisperm antibody formation, alterations in the hypothalamic-pituitary gonadal axis and oxidative stress. These factors may act synergistically and it may be difficult to explain the mechanism using one theory alone8

The controversy surrounding the treatment of varicocoeles is summarized by the difference in guidelines obtained from various professional groups. The American Urological Association and American Society for Reproductive Medicine recommends repair for men with palpable varicocoele and an abnormal semen parameter9. The National Collaborating Centre for Women and Children Health (2005) recommends that it should not be offered as a treatment option10 while the European Association of Urologists considers the treatment controversial11.

Despite numerous reports of pregnancies and restored fertility, few studies exist with an adequate experimental design to fully assess the utility of varicocoele repair in the treatment of fertility12. The relative paucity of studies assessing the effect of varicocoelectomy in this region necessitated the study at the University of Port Harcourt Teaching Hospital over a period of one year.

Patients and Methods

Ethical approval was obtained from the Research and Ethics Committee of UPTH. Participants were recruited from the hospital out-patient clinic. All consecutive male patients with history of infertility and had clinically palpable varicocoeles were included while infertile patients with history of torsion, trauma, congenital or syndromic diseases of the testicular function, history of mumps or orchitis and those who did not give consent were excluded.

All the information and data obtained were entered into a structured form constructed for the purpose of the study. This included the patient’s demographics, duration of infertility, frequency of coitus, history of previous conception, use of drugs and contraceptives.

Clinical examination findings noted were location of varicocoeles and grading using Dubins grading system13.

Each patient had two seminal fluid analyses done(the first at presentation and the second two weeks later) before surgery, a third four months after surgery and a fourth six months after surgery.

Surgery was an open inguinal varicocoelectomy (as described by Ivanissevich) with loupe magnification14; it was done as a day case procedure. With the patient supine on the operating couch, routine cleaning and draping was done and intravenous access secured. Anaesthesia was local anaesthesia with infiltration of 0.5% plain lidocaine. A 5-7 cm incision was made over the inguinal canal. The external oblique aponeurosis was opened and the spermatic cord was delivered and encircled. The cord structures were then carefully dissected and all internal spermatic cord veins ligated with the aid of optical loupes. The vas deferens and its vessels were preserved as well as the testicular artery and lymphatics. The cord was then elevated and any external spermatic veins that were running parallel to the spermatic cord or perforating the floor of the inguinal canal were identified and ligated. The wound was then closed in layers with vicryl 2/0 sutures and the skin with the same sutures. This same procedure was performed on the contralateral side. After the procedure the patient was placed on analgesics and observed for twenty four hours before discharge.

Sample Size was calculated using the formula for the comparison of means

n= 4z²×(PQ)2¹⁵

(d)2

Where P is set at 15% and Z at 1.96

n= the desired sample size

Z= the assumed standard deviation set at 1.96 which corresponds to 95% confidence interval

P= the population in the target population estimated to have a particular characteristic. 15% is used from previous studies.

Q= 1.0-p

d= the degree of accuracy desired at 20%

n=49

adding 10 % attrition rate;4.9

n=54

All the data generated were analyzed using SPSS statistical software 20.0. The independent samples t-test, Fischer’s exact test and chi-square test were used to test levels of significance with confidence intervals of 95%. A p-value of <0.005 was considered statistically significant.

Results

A total of 75 men were recruited for the study; 70 of them had varicocoelectomy while 54 returned for post surgery seminal fluid analysis.

The age range of patients was 19 54 years with a mean age of 38.8±6.17. The mean duration of infertility was 3.4years (range 1.3-7.4). This is illustrated in Table 1.

Pre-operatively, 11 (20.4%) were azoospermic, 28 patients (51.9%) had oligospermia and 15 (27.8%) patients had counts >20 million but less than 40 million.

Table 2 shows the effect of varicocoelectomy on all semen parameters of the patients. The mean preoperative semen volume was 3.4mls and the mean post-operative volume was 4.7mls with a mean difference of 1.3mls. A paired sample T-test showed this to be statistically significant with a p-value of ......

The mean sperm density pre-operatively was 12.9±12.6 x10⁶/ml, post-operatively this increased to 38.3±21.5 x10⁶/ml , a paired samples T test of p=0.00 showed that varicocoelectomy had a significant effect on sperm density.

The same findings were noted for semen morphology, which showed a statistically significant change between preoperative and postoperative values from 8.7±7.0% to 10.6±6.9% with a statistically significant p-value of 0.00.

Table 3 illustrates the effect of varicocoelectomy on patients with azoospermia. It was noted that there was an increase in semen volume from a mean of 2.6±1.3 ml to 4.3±1.2 ml. This was however not statistically significant. Improvements were also noted in the motility, density and morphology, these improvements were statistically significant with p=0.00.

Table 4 illustrates the effects of varicocoelectomy on patients with oligospermia. It was noted that the percentage change in mean motility was 51.2% ±19%; this value was higher than 20.8 % ±22.1% for azoospermic patients. This suggests that patients with oligospermia had a higher response in semen motility following varicocoelectomy than they did for other parameters.

It was also noted that after a paired sample T test, there was no statistically significant change in semen morphology for patients presenting with oligospermia with a p value of 0.160. The semen volume and semen density showed statistically significant changes with p=0.002 and p=0.000 respectively.

Discussion

The main findings from this study were that varicocoelectomy did improve the motility, morphology, volume, and density of semen in infertile males. This is in agreement with several other studies done in Africa and other continents 16^-18

In Sub-Saharan Africa, assisted reproductive techniques are expensive when available and considered an artificial method of procreation19, varicocoelectomy provides a cheaper (natural) method of achieving conception.

The various surgical techniques for treating varicocoeles included the retroperitoneal approach, conventional inguinal, laparoscopic, radiographic, microscopic inguinal and subinguinal approach. The failure rate for most of these procedures range from 3-15%, except for the microscopic approach with a failure rate of 1%, this necessitated the choice of this procedure20. Local anaesthesia was used, this has been shown to be simple, safe, effective, reliable and reproducible method of anaesthesia21. It offers lower morbidity, no notable adverse effects and allowed the patients return to regular physical activity.

Most of the patients in this study presented in the third and fourth decade of their lives. This may be because the study was targeted at the infertile male and that age bracket in the study environment was culturally accepted for marriage and procreation22. The age statistics are similar to those published from similar studies in University College Hospital Ibadan23 and University of Benin7 in other parts of Nigeria.

Azoospermic patients who presented with varicocoeles and had varicocoelectomy were also studied. It was noted in this subset of patients that while there was an increase in semen volume post surgery, it was not statistically significant; also the highest semen concentration post varicocoelectomy for an azoospermic patient was 17million cells/ml. The semen motility, morphology and concentration for azoospermic patients showed statistically significant changes. This study bore similar results to the study done by Kim et al17who studied 28 males but showed an improvement in semen concentration of 1.2±3.6 ×10⁶/ml , he also noted that none of the azoospermic patients was able to achieve natural conception.

The various approaches to varicocoelectomy and the differences in efficacy of treatment, recurrence and complication rates have made the analysis and comparison of studies difficult. Different randomised controlled trials to assess which studies meet satisfactory inclusion criteria and exclusion criteria seem to differ. The effect of sub-clinical varicocoeles on semen parameters has also made the analysis more complex. Most studies however agree to an improvement in seminal fluid analysis patterns13,16,24, the effect on spontaneous pregnancy rates remains more difficult to assess.

Our findings confirm that there was an improvement in semen parameters following varicocoelectomy in infertile males, in this resource challenged region, this could be one of the most cost effective methods for achieving spontaneous pregnancy. It is known that individuals with additional genetic abnormalities respond poorly to surgical treatment of varicocoeles24,25.

Limitation

A high dropout rate of 16(%) noted in this study . Another limitation to the methodology of the above study was the absence of genetic counselling and testingThis limitation was based on the absence of necessary equipment for such investigations.

The duration of the study was for only one year, while this may be appropriate for assessing the effect of seminal fluid parameters, the most important variable (which is the rate of spontaneous non assisted pregnancy) may not be properly assessed in the time utilized for the study.

Conclusions

This study has shown that varicocoelectomy improved seminal fluid analysis parameters; in azoospermic patients varicocoelectomy improved seminal fluid parameters, though the values were well below accepted values for spontaneous conception.

Table 1: Age distribution of the patients.

Age range in decades	Frequency	Percentage
11-19	1	1.9
20-29	1	1.9
30-39	29	53.7
40-49	20	37.0
50-59	3	5.6
Total	54	100.0

Table 2: Effects of varicocoelectomy on all the patients.

WHO semen criteria	Preoperative mean ± SD	Postoperative mean ± SD	Mean p-value
Volume (ml)	3.4 ± 1.5	4.7 ± 1.5	0.044
Motility (%)	29.0±22.2	46.4 ± 22.6	0.000
Density (× 106/ml)	12.9±12.6	38.3 ± 21.5	0.000
Morphology (%)	8.7±7.0	10.6 ± 6.9	0.000
95%CI, 95% Confidence Interval, SD, Standard deviation; WHO, World Health Organization

Table 3: Effects of varicocoelectomy on patients with azoospermia.

WHO Semen Criteria	Preoperative mean ± SD	Postoperative mean ± SD	p-value
Volume (mls)	2.6 ± 1.13	4.3 ± 1.2	0.98
Motility (%)	0.0 ± 0.0	20.8 ±22.1	0.00
Density (× 106/ml)	0.00 ± 0.0	16.3 ± 16.5	0.00
Morphology (%)	0.00 ± 0.0	10.3±8.6	0.00
95%CI, 95% Confidence Interval, SD, Standard deviation; WHO, World Health Organization

Table 4: Effects of varicocoelectomy on patients with oligospermia.

WHO Semen criteria	Preoperative mean ± SD	Postoperative mean ± SD	Mean p-value
Volume	3.6 ± 1.7	4.9 ± 1.5	.002
Motility (%)	31.9±19.2	51.2±19.2	.000
Density (×106/ml)	8.5 ± 5.4	38.5 ± 18.7	.000
Morphology (%)	11.4±6.7	10.6±6.8	.160
95%CI, 95% Confidence Interval, SD, Standard deviation; WHO, World Health Organization