Out Come Of Varicocele Surgey Biology Essay

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This descriptive study was conducted on a total of 844 patients who underwent Varicocele surgery at Prince Hussein urology center, for infertility between the period of June 2003 and June 2008, surgery was performed for patients upon presenting to our clinic complaining of infertility for one year or more in the absence of female factor for infertility. Patients were non-randomly selected. Sperm concentration , motility and morphology was assessed by analysis of at least two different semen specimens each obtained after a 5 days period of sexual abstinence and separated by three weeks interval. Post surgery patients were classified as responders (more than 50% increases in sperm parameters) and non responders. Simple statistical method (frequency, mean and percentage) was used to describe the study variables.

Results:-

Surgical treatment of clinical palpable Varicocele successfully cured over 95% of Varicocele. Post surgery spermatogenesis was improved in 256 patients (30.3%),

Sperm concentration increased to variable degrees from 6.23 to 12.1 million among these patients with mean of 9.2 million, sperm motility improved from 5.2% to 18.7% with mean of 8.3%. Spontaneous pregnancy was achieved in 194(23%) couples within 12 months following surgery.

Conclusion:-

Varicocelectomy is safe, effective and associated with a rapid recovery and minimal morbidity. Varicocelectomy resulted in the induction or enhancement of spermatogenesis to several men with clinical Varicocele and abnormal semen parameters. Despite the absence of definitive studies on the infertility outcome of Varicocele surgery, it is reasonable to be considered as an option in selective patients with semen abnormalities.

Keywords: - Infertility, Spermatogenesis, Varicocele.

Introduction:-

Varicocele , which is abnormal tortuosity and dilation of veins of pampiniform plexus within the spermatic cord, is the most commonly seen and correctable cause of male factor infertility (1), although it presents in 15% of general male population , 40% of men presenting with infertility have Varicocele (2). The reason for infertility associated with Varicocele are unclear, perhaps the accumulation of blood cause the testes to be hotter and so damage sperm production; or the pooled blood brims over with abnormal hormones which may change the way the testes make sperms (3).

Only Varicocele detected by physical examination should be considered potentially significant, and if the Varicocele coexists with impaired semen quality, surgical repair may potentially restore spermatogenesis and fertility. (4).

Varicocele can be treated surgically (open and laparoscopic) or radiologically. (5).

Varicocele frequency found to be higher in first degree relatives especially among brothers. (6).

This study aims to determine the outcome of surgical techniques for the treatment of testicular varicosity to improve fertility among infertile male at Prince Hussein Urology Center.

Methods:-

This descriptive study was conducted on a total of 844 patients who underwent Varicocele surgery at Prince Hussein urology center, for infertility between the period of June 2003 and June 2008, surgery was performed for patients upon presenting to our clinic complaining of infertility for one year or more in the absence of female factor for infertility. Patients were non-randomly selected. Post surgery patients were classified as responders (more than 50% increases in sperm parameters) and non responders. Patients were followed for one year after surgery.

Varicocelectomy was performed using inguinal approach (groin) in 196 patients, retroperitoneal (abdominal) approach in 600 cases and laparoscopic varicocelectomy in 48 cases.

Isolated left side varicocelectomy were performed in 766 patients, right side in 4 cases and bilateral varicocelectomy in the remaining 74 patients.

Patients age range between 20 years up to 40 years with mean age of 28 years.

Sperm concentration , motility and morphology were confirmed by analysis of at least two different semen specimens each obtained after a 5 days period of sexual abstinence and separated by three weeks interval according to World Health Organization guidelines classification , before surgery and then three and six months after surgery. Azospermia was confirmed in the absence of sperms in all analysis, severe oligospermia was defined as less than 5 millions /ml in all analysis submitted.

Post surgery patients were classified as responder (more than 50% increases in sperm count) and non responder.

Serum follicular stimulating hormone, luteinizing hormone, prolactin and testosterone level were checked prior to surgery to exclude other endocrine causes for infertility.

Out of 844 patients, 826 patients underwent the procedure on the basis of out patient’s surgery and discharged same day of surgery, 4 patients were admitted one day before surgery due to underlying medical illnesses and discharged first day after surgery, 14 patients were admitted after surgery for one day due to pain intolerability. Simple statistical method (frequency, mean and percentage) was used to describe the study variables.

Results:-

We found that surgical treatment of clinical palpable Varicocele successfully cured in over 95% of Varicocele in our patients. Post surgery spermatogenesis was induced in 256 (30.33%),

Sperm concentration increased to variable degrees from 6.23 to 12.1 million in some patients with average of 9.2 million, sperm motility improved from 5.2% to 18.7% with average of 8.3%.

Fourteen patients were admitted post surgery because of pain intolerability and high dose of analgesia were given and patients were admitted for observation and discharged second day. Three cases with simple wound infection treated by daily dressing and healed completely, 8 patients (1%) presented with hydrocele after surgery, 40 patients (5%) presented with recurrence of varicocele. Spontaneous pregnancy was achieved in 194 (23%) couples within 12 months following surgery.

Most patients could go back to work three weeks after surgery.

Discussion:-

The study conducted by Kim et al revealed that early varicocelectomy repair especially for large varicocele may be beneficial in preventing future infertility as well as treatment of androgen deficiency (7). Pathophysiologic effect of varicocele on spermatogenesis is related to testicular hyperthermia. (8). Fujjsawa et al,1994 support the theory of reflux of toxic metabolites from renal and adrenal glands secondary to venous reflux have been implicated to hypospermatogenesis.(9).

Skoog et al consider that the testicular hypoxia is caused by venous stasis in varicocele. (10). Marcello Cocuzza et al found that the improvement of semen parameters following varicocelectomy help infertile people to achieve spontaneous pregnancy (4).

Ali Shamsa et al found that the laparoscopic has more complications than open approach regarding operative time, recurrence and hydrocele formation (5).

The correlation between severity of Varicocele and improvement of semen parameters after surgery remains equivocal. (6).

Andrade et al conduct a study on 143 patients with varicocele found that sperm quality is affected more than sperm quantity in all male age groups. (11).

Cayan et al (4) showed that open microsurgical inguinal or subinguinal varicocelectomy techniques have been shown to result in higher spontaneous pregnancy rates and less recurrence.

Treatment options for Varicocele in infertile men may be treated with many different modalities including radiologic, laparoscopic and open surgical approaches (7, 8, 9, and 10). Postoperative results for fertility suggest that Varicocele repair significantly increase sperm motility and total sperm count postoperatively (11). Spontaneous pregnancy rate after varicocelectomy range from 16% to 55.2% (12). In the meta-analysis reviewed by Kim et al, the overall spontaneous pregnancy rate was 37.69% in the Paloma technique series (7), which was higher than our results. However, spontaneous pregnancy rates after varicocelectomy may differ depending on post surgery follow up interval, the presence of female factors and other reproductive health factors (1).

However; spontaneous pregnancy rate for patients with Varicocele and abnormal semen parameters estimated to be 10% which was lower than our results. Ishikawa T et al (12) assessed the outcome of Varicocelectomy in the induction of spermatogenesis and they noticed that surgery for varicocele enhance spermatogenesis for several men with unobustructive or severe oligospermia.

Other studies confirmed no benefit of varicocelectomy over expectant management in subfertile couples in whom Varicocele is the only abnormal finding (13, 14).

Further analytical follow-up studies using Doppler ultrasound for the diagnosis of varicocele with a larger number of patients is needed.

Conclusion:-

Varicocelectomy is safe, effective and associated with a rapid recovery and minimal morbidity. Varicocelectomy resulted in the induction or enhancement of spermatogenesis to several men with clinical Varicocele and abnormal semen parameters. Despite the absence of definitive studies on the infertility outcome of Varicocele surgery, it is reasonable to be considered as an option in selective patients with semen abnormalities.

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