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Sandro Esteves, MD, PhD
Director, ANDROFERT Center for Male Reproduction and Infertility
Campinas, BRAZIL
Insight’12 – Lite, Coimbatore, India – May 2012
Varicocele: Prevalence Va
ricoc
ee
• 15% male population • 35% of male infertility cases
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Varicocele: Physical Examination
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Varicocele: Use of Pencil-probe Doppler
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ROS-induced DNA damage
Sertoli Cell
Spermatogonia
Spermatocytes
Early spermatids
Elongated spermatids
Mature spermatozoa
Epididymis
Vas Deferens
Seminiferous Tubules
Alvarez and Sakkas, Fertil Steril, 2010
Varicocele: Pathophysiology
Courtesy of Prof. Juan Alvarez
Sur
gica
l Tr
eatm
ent
• Indication for Treatment: Clinical (palpable) varicocele and Abnormal semen analysis results
Varicocele: Treatment
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Technique Internal Spermatic
Vein Ligation
External Spermatic
Vein Ligation
Recurrence Rate
Hydrocele Formation
Rate
Spontaneous Pregnancy
Rate
Retroperitoneal High-Ligation (Palomo)
Yes No 7-35% 6-10% 25-55%
Laparoscopic Yes No 2-7% 0-9% 14-42% Embolization Yes No 2-24% NR 20-40% Macroscopic Inguinal (Ivanissevich)
Yes Yes 0-37% 7% 34-39%
Microscopic Inguinal or Subinguinal45,51,54,55
Yes Yes 0-0.3% 0-1.6% 33-56%
Surgical Treatment of Varicocele
Miyaoka & Esteves. Critical appraisal on the role of varicocele in male infertility. Adv Urol 2012; Epub Esteves, 8
Fertility Restoration Spontaneous Pregnancy
Surgical Treatment of Varicocele
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Varicocelectomy for Fertility Restoration
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Fertil Steril 2007;88:639–48.
Implications for Practice • Varicocele treatment S
urgi
cal
Trea
tmen
t • Effect • Decrease seminal oxidative stress • Improve sperm DNA integrity • Improve semen parameters • Increase the likelihood of
spontaneous and assisted pregnancy
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Fertility Improvement
Sperm Retrieval in
Azoospermia
Fertility Improvement
ICSI
Outcomes Fertility Restoration Spontaneous Pregnancy
Surgical Treatment of Varicocele • It can improve success of ART
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Varicocele Repair Before ICSI
Microsurgical varicocele repair prior
to ICSI (N=80)
ICSI in the presence of varicocele (N=162)
6.7
15.4
Total Number of Motile Sperm (x106)
Pre-op Post-op
P<0.01
Clinical Outcome of Intracytoplasmic Sperm Injection in Infertile Men With Treated and Untreated Clinical Varicocele
SC Esteves, FV Oliveira, RP Bertolla. ANDROFERT, Center for Male Reproduction, Campinas, BRAZIL and Division of Urology, São Paulo Federal
University, São Paulo, BRAZIL.
The Journal of Urology Vol. 184,1442-1446, October 2010
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78%*
46%*
22%
66%
31% 31%
Varicocele and ICSI Outcomes
Treated Varicocele Untreated Varicocele
Fertilized Eggs (%2PN)
Live Birth (%)
*P<0.05
Miscarriage (%)
Esteves SC, Oliveira FV, Bertolla RP. Clinical Outcome of ICSI in Infertile Men with Treated and Untreated Clinical Varicocele. J Urol 2010;184:1442-1446
Odds ratio 1.87 0.43 95% CI 1.08 - 3.25 0.22 – 0.84 P-value 0.03 0.01
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Varicocele Repair Before Sperm Retrieval Sperm Retrieval and Intracytoplasmic Sperm Injection in Men With Nonobstructive Azoospermia, and Treated and
Untreated Varicocele K Inci, M Hascicek, O Kara et al. Department of Urology, School of
Medicine, Hacettepe University, Ankara, Turkey.
The Journal of Urology Vol. 182,1500-1505, October 2009
53% 30%
Successful Sperm Retrieval Rate
Treated VaricoceleUntreated Varicocele
OR: 2.63 (95% CI: 1.05-6.60; P=0.03)
Microsurgical varicocele repair prior to sperm retrieval ICSI
(N=66)
Sperm Retrieval in the presence of varicocele
(N=30)
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Take-home Messages Evidence for a Positive Impact in the Surgical Treatment of Clinical
Varicoceles : 1. Increase the likelihood of spontaneous
conception in men with mild/moderate abnormal semen parameters.
2. Increase the odds of live birth in subgroups of men with severe oligozoospermia
undergoing ICSI. 3. Increase the chance of having a successful
sperm retrieval in the subgroup of patients with non-obstructive azoospermia.
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