Comparison of pre-operative and post-operative (varicocelectomy) sperm parameters in patients suffering varicocle with and without reflux in Doppler ultrasonography.

BACKGROUND: Varicocele can cause progressive testicular damage and infertility. Severe retrograde blood flow to the internal spermatic vein has been suggested as a risk factor for infertility or progressive/stable varicocele. We have aimed to Compared th pre-operative and post-operative (varicocelectomy) sperm parameters in patients suffering varicocle with and without reflux in Doppler ultrasonography.
METHODS: This descriptive-analytic study was carried out at the Imaging Center of Ahwaz University of Medical Sciences in Imam and Golestan Hospitals. The parameters assessed included the presence or absence of internal spermatic vein reflux in both sided. Patients were divided into three groups based on the presence of testicular reflux: no reflux, left-sided reflux, and both sides reflux. The reflux longer than 1 second was considered pathologic. All patients were also referred to the laboratory for semen analysis, including semen volume, sperm morphology, sperm counts, and motility. Semen analysis was repeated 2 months after varicocelectomy.
RESULTS: In this study, a total of 70 patients were evaluated. Forty-three patients (61.4%) did not have any reflux, 23 patients (32.9%) had left testicular reflux, and 4 (5.7%) had reflux in both testicles. Semen volume, number of sperms, number of motile sperm, and sperm morphology increased significantly after Varicocelectomy. We did not find any significant correlation between testicular reflux and improvement index of semen analysis factor was found.
CONCLUSION: The findings of this study indicate that the presence of testicular reflux has no effect on semen analysis parameters, but also does not predict the consequences of varicocelectomy and therefore is not a suitable prognosis factor in varicocele patients.

Introduction

Varicocele is an abnormal tortuosity and dilatation (more than 2 mm) of the spermatic veins and pampiniform plexus, which more found on the left side. Varicocele can cause progressive testicular damage and infertility. It is found in 15–20% of the general population and 35–40% of men who refer to infertility assessment.[123] Its standard diagnostic method is clinical examination, but some irregular and asymptomatic patients may need to undergo other diagnostic procedures specially ultrasonography.[4] Varicocele is known as a cause of male infertility, which can be treated with varicocelectomy. Varicocelectomy is the most common treatment option for this purpose, since the results of supportive care are even vague in patients with idiopathic infertility. On the other hand, choosing the right candidate for surgery is also important.

Ultrasonography is a primary modality for the diagnosis of varicocele. The diameter of the vein is measured using B-mode sonography and the venous reflux is also evaluated using Doppler sonography.[5] Color doppler ultrasonography has a sensitivity of 93% and 85%, compared to a physical examination for varicocele detection.[6] Venous reflux (retrograde flow in the testicular vein) is an important criterion for detecting varicocele. It has been reported that the reflux more than 1 second increases the probability of infertility.[7] Also, in recent years, severe retrograde blood flow to the internal spermatic vein has been suggested as a risk factor for infertility or progressive/stable varicocele.[8] Some studies considered the vein dilation alone, and others, reported the co incidence of venous reflux as an important affective factor in sperm production. Due to the observation of reflux in a significant percentage of normal people, some authors suggested the neglecting of the factor. However, there are not enough studies to determine whether the presence or absence of reflux is associated with varicocelectomy outcones. Therefore, the aim of this study was to compare the parameters of sperm before and after varicocelectomy in patients with or without reflux during Doppler ultrasonography.

Materials and Methods

Study design

This descriptive-analytic study was carried out at the Imaging Center of Ahwaz University of Medical Sciences in Imam and Golestan Hospitals. After approval of the study protocol by the Ahvaz Jundishapour University of Medical Scicens's Ethics Committee, patients with varicocele were enrolled in the study. Consent informed were given to all participants. Patients with secondary varicocele, traumatic injury and other testicular disorders (such as tumors, hydrocele, spermatocell) or testicular inflammation or epididymis were excluded.

Measurements

The selected patients were initially undergoing gray-scale ultrasound for varicocele and cases with a diameter of more than 2 mm were considered for further evaluation. More assessment were done using color Doppler ultrasound system with multi-frequency linear probe (5–8.5 MHz). Patients were put in supine position and examined by Valsalva maneuver. The parameters assessed included the presence or absence of internal spermatic vein reflux in both sided. The reflux longer than 1 second was considered pathologic. All patients were also referred to the laboratory for semen analysis, including semen volume, sperm morphology, sperm counts and motility. Semen analysis was repeated 2 months after varicocelectomy. Semen analysis was reported according to 1993 WHO guidelines.

Statistical analysis

Descriptive analysis including mean, standard deviation and frequency for all variables was performed. The comparison of quantitative variables was performed by paired t-test and Analysis of variance (ANOVA). Comparison of proportions was performed using Chi-square test. All statistical analysis was performed using SPSS version 19. P value less than 0.05 considered significant.

Results

In this study, a total of 70 patients were evaluated. The mean diameter of the right and left side testicular vein at the standing, resting and during Valsalva maneuver was shown in Table 1. The sperm analysis factors before and after surgery was shown in Table 1. Forty-three patients (61.4%) did not have any reflux, 23 patients (32.9%) had left testicular reflux, and 4 (5.7%) had reflux in both testicles.

Table 1

Descriptive statistics

Variables	Mean	Std. Deviation	Minimum	Maximum
Right testis vein diameter-Resting	1.98	0.43	1.5	2.6
Right testis vein diameter-Standing	2.37	0.45	1.5	3.0
Right testis Vein diameter in Valsalva maneuver	2.57	0.43	2.0	3.5
Left testis vein diameter-Resting	2.84	0.28	2.0	3.5
Left testis vein diameter-Standing	3.16	0.32	2.5	3.5
Left testis Vein diameter in Valsalva maneuver	3.46	0.24	3.0	4.0
Preoperative semen volume	2.35	0.98	1.2	5.0
Preoperative Sperm count	30.54	24.61	1.00	84.00
Preoperative Sperm motility	33.18	11.31	10.0	60.9
Preoperative Sperm Morphology	32.37	12.4	15	60
Postoperative semen volume	3.92	5.49	1.2	35.0
Postoperative Sperm count	47.56	31.0	6	120
Postoperative Sperm motility	41.59	14.0	6	65
Postoperative Sperm Morphology	41.06	13.50	14	70

Patients were divided into three groups based on the presence of testicular reflux: no reflux, left-sided reflux, and both sides reflux. The diameter of testicular veins was compared in different positions including standing, resting, and during Valsalva maneuver in all three groups. Based on these findings, the left testicular vein diameter at standing, resting, and Valsalva maneuver showed significant differences between the three groups (P = 0.003, P = 0.017, P = 0.005, respectively). The lowest level was seen in patients without reflux and its highest level was seen the simultaneous incidence of reflux in both testicles. However, the right testicular vein diameter did not show any significant difference between the three groups at different position [Table 2].

Table 2

Testicular veins diameter comparisons between the groups

Variables	Groups	Mean	Std. Deviation	Minimum	Maximum	Sig.
Right testis vein diameter-Resting	None	1.900	0.4237	1.5	2.6	0.017
	Left Side	2.065	0.4344	1.5	2.5
	Both side	2.500	0.0000	2.5	2.5
Right testis vein diameter-Standing	None	2.267	0.4545	1.5	3.0	0.003
	Left Side	2.478	0.4045	2.0	3.0
	Both side	3.000	0.0000	3.0	3.0
Right testis Vein diameter in Valsalva maneuver	None	2.523	0.4076	2.0	3.0	0.005
	Left Side	2.565	0.4344	2.0	3.0
	Both side	3.250	0.2887	3.0	3.5
Left testis vein diameter-Resting	None	2.802	0.3211	2.0	3.5	0.102
	Left Side	2.952	0.1880	2.5	3.2
	Both side	2.750	0.2887	2.5	3.0
Left testis vein diameter-Standing	None	3.137	0.3625	2.5	3.5	0.274
	Left Side	3.239	0.2426	2.8	3.5
	Both side	3.000	0.0000	3.0	3.0
Left testis Vein diameter in Valsalva maneuver	None	3.456	0.2363	3.0	4.0	0.131
	Left Side	3.513	0.2399	3.0	4.0
	Both side	3.250	0.2887	3.0	3.5

All parameters studied in semen analysis including semen volume, number of sperms, number of motile sperm and sperm morphology increased significantly after Varicocelectomy [Table 3]. The improvement index (less than 0.5 good recovery, greater than 0.5 worse recovery) in semen analysis factors was compared between the groups. The results showed no significant correlation between testicular reflux and improvement index of semen analysis factor [Table 4].

Table 3

Comparison of the parameters of semen analysis before and after Varicocelectomy

Variables	Minimum	25% Percentile	Median	75% Percentile	Maximum	Mean	Std. Deviation	Significance
Semen Volume
Before	1.2	1.5	2.0	3.0	5.0	2.4	1.0	P=0.014
After	1.2	2.0	2.5	4.0	35.0	3.9	5.5
Semen Counts
Before	1.0	13.8	22.5	40.0	84.0	30.6	24.6	P<0.0001
After	6.0	24.3	40.0	80.0	120.0	47.6	31.0
Motility
Before	10.0	23.8	35.0	40.0	60.9	33.2	11.3	P<0.0001
After	6.0	30.0	42.0	55.0	65.0	41.6	14.0
Morphology
Before	15.0	25.0	30.0	40.0	60.0	32.4	12.4	P<0.0001
After	14.0	31.5	38.0	55.0	70.0	41.1	13.6

Table 4

Improvement index comparison in different groups

Variables	Group	Good	Poor	Sig
Semen Volume	No	7 (16.3%)	36 (83.7%)	0.116
	Left Side	8 (34.8%)	15 (65.2%)
	Both side	2 (50%)	2 (50%)
	Total	17 (24.3%)	53 (75.7%)
Sperm Count	No	24 (55.8%)	19 (44.2%)	0.507
	Left Side	16 (69.6%)	7 (30.4%)
	Both side	2 (50%)	2 (50%)
	Total	42 (60%)	28 (40%)
Sperm Morphology	No	14 (32.6%)	29 (67.4%)	0.306
	Left Side	9 (39.1%)	14 (60.9%)
	Both side	0 (0%)	4 (100%)
	Total	23 (32.9%)	47 (67.1%)
Testicular veins reflux	No	15 (34.9%)	28 (65.1%)	0.242
	Left Side	10 (43.5%)	13 (56.5%)
	Both side	0 (0%)	4 (100%)
	Total	25 (35.7%)	45 (64.3%)

Discussion

In this study, 70 patients were examined, all of them underwent testicular ultrasonography and sperm analysis before and after surgery. Overall, 43 patients had no Testicular reflux had, 23 patients (32.9%) showed left testicular reflux and both-sided testicular reflux was seen in 4 (5.7%) patients. These findings were in line with studies had done by ultrasound and were relatively less than that performed using venography.[91011] In studies done by venography, 100% of varicocele patients had reflux, which could be due to more precision of venography, or because of the insertion the catheter tip into the spermatic vein entry, can caused bypassing critical valves.

In the present study, all four evaluated factors thorough semen analysis showed a significant improvement after varicocelectomy. Similarly, in a study conducted by Al Bakri et al., the mean sperm counts were significantly increased after 3-6 months after varicocelectomy. While, they have failed to find any significant improvement in respect of semen volume, motile sperm count, Sperm count, and total sperm motility after surgery.[12] In a study performed by Pogorelić Z et al., The rate of motility, morphology and sperm concentration 6 months after surgery was improved in patients with varicocele grade 1 and 2. In patients with varicocele grade 3, only morphology and sperm concentration were improved, while sperm motility did not change significantly.[13] Varicocele grade was not evaluated in our study. Many studies, including recently published Meta-analyzes, have found that varicocele has a significant effect on semen parameters including count, motility, and sperm morphology.[14]

In this study, there was no correlation between the testicular reflux and semen analysis improvement after varicocelectomy. These findings suggest that the presence of reflux alone does not have prognostic value and could not affect the spermatogenesis. These findings were in line with other previous studies.[1415] In the study of Ghafouri et al., There was no association the testicular reflux (less than one-second) semen analysis parameters including all three major criteria (number of sperm, motile sperm, and abnormal morphology), which shows that it could not predict the spermatogenesis changes in patients with varicocele.[15] However, in a study conducted by Tahmasbi et al., A significant relationship between testicular reflux and abnormal semen analysis. They also concluded that the presence of bilateral intravenous reflux or sustained intravenous reflux on each side is an important predictor of the abnormal semen analysis.[16] Also, Mahdavi et al., In contrast to the results of this study, showed that patients with reflux longer than 1 second compared with patients with reflux less than 1 second had a significant differences in terms of semen analysis parameters.[5]

The findings of this study also showed that there is no significant relationship between Semen analysis improvement index and testicular reflux. Also, we have found that the presence of testicular reflex has no effect on treatment response as the results showed no significant differences between patients with or without testicular reflux in terms of semen analysis improvement index. In a study by Alayman F. Hussein in Egypt, improvement index in semen analysis parameters has been compared in patients with testicular reflux at the lower testicle bridge and patients with reflux only in supra-testicular artery. They have found a significantly higher improvement index in patients with anterior bridge reflux.[17] In the present study, we compared the difference in surgical outcomes in patients with and without reflux, in the study of Alayman and colleagues, a comparison was made between surgical outcomes in patients with anterior bridge reflux and patients with reflux in the supra-testicular artery. Hence, the contrary with our results, could be due to the differences in study protocol.

Overall, the findings of this study indicate that the presence of testicular reflux has no effect on semen analysis parameters, but also does not predict the consequences of varicocelectomy and therefore is not a suitable prognosis factor in varicocele patients.

Ethical standards

All procedures have been approved by the appropriate ethics committee and have therefore been performed inaccordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Informed consent

Informed consent was signed prior to participation in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.