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The Effect of Prior Varicocelectomy in Patients With Nonobstructive Azoospermia on Intracytoplasmic Sperm Injection Outcomes: A Retrospective Pilot Study
Infertility The Effect of Prior Varicocelectomy in Patients With Nonobstructive Azoospermia on Intracytoplasmic Sperm Injection Outcomes: A Retrospective Pilot Study Bulent Haydardedeoglu, Tahsin Turunc, Esra Bulgan Kilicdag, Umit Gul, and Tayfun Bagis OBJECTIVES
METHODS
RESULTS
CONCLUSIONS
To examine our retrospective data on the outcomes of intracytoplasmic sperm injection (ICSI) and to determine whether a history of varicocele repair in men with nonobstructive azoospermia (NOA) undergoing an ICSI cycle was optimizing or not. This retrospective study was conducted on Baskent University Department of Obstetrics and Gynecology, IVF Unit, and Department of Urology. Infertile couples suffering from NOA scheduled to an ICSI cycle, which was controlled ovarian hyperstimulation with a gonadotropin or gonadotrophin-releasing hormone-agonist protocol, selected for the study were divided into 2 groups: group 1 (n ⫽ 31) included NOA patients who had undergone prior varicocele repair, and group 2 (n ⫽ 65) included NOA patients who had not undergone varicocele repair. There was a significant difference between the 2 groups considering the sperm retrieval rate, which was higher in the varicocele repair group (sperm retrieval rate 60.81% and 38.46% respectively, P ⫽ .01). The clinical pregnancy rate and live birth rate were significantly higher in the varicocelectomy group (74.2% vs 52.3% and 64.5% vs 41.5%, respectively, P ⬍.05). Varicocele repair in NOA might be considered in patients undergoing ICSI cycle. UROLOGY 75: 83– 86, 2010. © 2010 Elsevier Inc.
T
he ability to retrieve sperm from the testes along with the discovery that these spermatozoa are capable of fertilizing an egg and producing a live, healthy offspring by intracytoplasmic sperm injection (ICSI) has changed the reproductive options for azoospermic men. Testicular sperm extraction (TESE) has been used successfully to retrieve sperm directly from seminiferous tubules, and can result in oocyte fertilization when combined with ICSI. Varicocele in association with azoospermia is estimated to range between 5% and 10%, and studies have clearly shown the beneficial effect of varicocele repair in azoospermic cases.1,2 Although these men had no sperm in their ejaculate, it was discovered on testicular biopsy that they often had isolated pockets of sperm production in their testes from which sperm could be retrieved.3 The success rate of varicocele repair in nonobstructive azoospermia (NOA) is still controversial. A history of prior varicocele repair does not seem to affect the chance of sperm retrieval by TESE for men From the Departments of Obstetrics and Gynecology and Urology, Baskent University Faculty of Medicine, Adana, Turkey Reprint requests: Bulent Haydardedeoglu, M.D., Department of Obstetrics and Gynecology, Baskent University Faculty of Medicine, Cemalpasa Mah 5 Sokak Ferah Apt Kat 9 no 18 Seyhan, Adana, Turkey. E-mail: [email protected] Submitted: June 5, 2009, accepted (with revisions): September 9, 2009
© 2010 Elsevier Inc. All Rights Reserved
with clinical varicoceles and NOA.4 However, after varicocele repair, one study found a return of sperm to the ejaculate in 12 of 28 (43%) men with NOA at an average follow-up of 24 months.5 Furthermore, motile sperm in the ejaculate of azoospermic patients yields superior ICSI success rates compared with sperm obtained by TESE.6 Thereby, varicocele repair in completely azoospermic men has also prompted investigators to determine the effect of this procedure on spermatogenesis in NOA. The effect of varicocelectomy in NOA on ICSI outcomes has not been evaluated in the literature. Thus, our aim was to examine our retrospective data on ICSI outcomes to determine whether a history of varicocele repair in men with NOA undergoing an ICSI cycle was optimizing or not.
MATERIAL AND METHODS This study was conducted from November 2003 to April 2008 in the Division of Reproductive and Endocrinology Unit, Department of Gynecology and Obstetrics, and Department of Urology, at Baskent University. Microdissection TESE had been applied to 269 NOA patients. The number of NOA patients with previous macrosurgical varicocelectomy operation was 74 and the number of NOA patients without varicocelectomy surgery was 195. In total, 120 TESE patients diagnosed 0090-4295/10/$34.00 doi:10.1016/j.urology.2009.09.023
83
with NOA were eligible to participate in the ICSI program for this study. Patients who had undergone an ICSI cycle with a long-luteal gonadotrophin-releasing hormone (GnRH) agonist protocol were selected to obtain uniform data and to minimize the female factor. Nine patients undergoing a long-luteal GnRH agonist protocol were excluded from the study due to the cancelation of embryo transfer because of fertilization failure. Microdose flare and GnRH antagonist protocols were omitted from the study, which included 15 patients diagnosed as poor responders (⬍6 oocytes in the ovum pick up) and potential poor responders (follicle-stimulating hormone ⬎10 mIU/L and antral follicle count ⬍6). Thereby, the first cycles of 96 patients were included in our study. According to our clinical policy, patients suffering from NOA who were going to undergo an ICSI cycle were offered fresh TESE during oocyte retrieval or cryopreservation of a sperm sample and survival after thawing was checked. In the cryopreservation group, TESE was performed for freezing 3 months before oocyte retrieval. Patients from whom sperm was not obtained by TESE and those from whom sperm was obtained from their ejaculate were excluded from the study. Previous varicocelectomy was determined from each patient’s anamnesis and their operation notes. The severity, localization, and operation time of varicocele repair were recorded. All varicocele repair patients had been operated on due to grade 3 varicocele. Operations for grade 1 and grade 2 varicocele had not been performed, but there was no varicocele in all patients with NOA in the study group, which was diagnosed by the Doppler ultrasonography. All varicocelectomy operations were macrosurgical varicocelectomy which were recorded from their operation notes. After 6 months of varicocele repair, all NOA patients’ sperm analyses were assessed on at least 3 spermiograms to put correct diagnosis of azoospermia. Microdissection TESE was performed by making a 3- to 4-cm incision in the tunica albuginea under operating microscopy, avoiding the underlying testicular artery. Seminiferous tubules that appeared dilated and opaque were harvested. Before the microdissection TESE operation, a chromosomal assessment was performed in all NOA patients. The patients selected for the study were divided into 2 groups: group 1 (n ⫽ 31) included NOA patients who had undergone prior varicocele repair, and group 2 (n ⫽ 65) included NOA patients who had not undergone varicocele repair. Fourteen NOA patients in the varicocele repair group and 10 NOA patients in group 2 were omitted from the study due to their poor responder spouse. Ovarian downregulation was initiated with daily leuprolide acetate 1 mg (Lucrin, Abbott, France), beginning on the 21st day of the preceding menstruation. After ovarian suppression was achieved, the dose was reduced to 0.5 mg until the day of human chorionic gonadotropin (hCG). If there were no cysts ⱖ 2 cm and the E2 was ⬍50 pg/mL, gonadotropin stimulation with 150-300 IUs of gonadotropins (Gonal-F, Serono, Randolph, MA) was performed, with E2 monitoring commencing on the morning of stimulation day 5. Ultrasound and blood E2 monitoring continued until hCG administration criteria were met with at least 3 follicles having a maximum diameter of ⬎17 mm. Transvaginal ultrasound-guided oocyte retrieval was performed 35-36 hours after the hCG injection. Oocyte pick-up was performed with a 17-gauge needle for oocyte retrieval under sedation with propofol (propofol 1% Fresenius Kabi, Germany). The oocyte-corona complexes were denuded, and ICSI was performed after 2 hours of incubation and the embryos were 84
Table 1. The basal characteristics of men with NOA NOA With Varicocelectomy (n ⫽ 74) Age (y) FSH (mIU/L) Testis volume Sperm retrieval rate (%)
NOA Without Varicocelectomy (n ⫽ 195)
35.06 ⫾ 6.40 35.20 ⫾ 6.09 16.73 ⫾ 13.65 17.89 ⫾ 12.24 14.35 ⫾ 6.7 13.66 ⫾ 6.82 60.8% (45/74) 38.46% (75/195)
P NS NS NS .01
NS ⫽ not significant.
transferred on day 3. The embryo transfer policy depends on the number and quality of embryos developed. The transfer protocol was individualized for a maximum of 4 poor grade embryos. All patients received luteal support with 90 mg progesterone intravaginally (Crinone 8% gel, Serono, Randolph, MA) daily after embryo transfer. Clinical pregnancy was defined as the presence of at least 1 gestational sac with detectable fetal cardiac activity by transvaginal ultrasonography. Live birth was defined as delivery time after 27 weeks of gestation with at least 1 live baby.
Statistical Analysis Data are expressed as means ⫾ SD. The baseline differences between the 3 groups were analyzed by one-way analysis of variance. In contingency tables, the chi-square test or the two-sided Fisher exact test was performed. A value of P less than .05 was considered statistically significant. The data were analyzed using SPSS for Windows (version 11.0; SPSS, Inc., Chicago, IL).
RESULTS Microdissection TESE had been applied to 269 NOA patients whose sperm retrieval rate was 44.9%. There was a significant difference between the 2 groups in consideration with the sperm retrieval rate which was higher in the varicocele repair group (sperm retrieval rate 60.81% and 38.46% respectively, P ⫽ .01) (Table 1). The basal characteristics of the 2 groups of NOA patients were similar (Table 1). The ICSI cycle characteristics are shown in Table 2. There was no significant difference between NOA patients with varicocelectomy and the group that did not undergo surgery in consideration with the ICSI cycle characteristics. However, implantation rates, clinical pregnancy rate, and live birth rate were significantly higher in the varicocelectomy group (40.59 ⫾ 32.64% vs 26.05 ⫾ 29.83%, 74.2% vs 52.3%, and 64.5% vs 41.5%, respectively, P ⬍.05) (Table 2). Grade 1 embryo numbers seemed to be superior in the varicocelectomy group, but the differences were not statistically significant (1.74% vs 1.4%, P ⬎.05) (Table 2). We compared the time interval between varicocele repair and TESE considering clinical pregnancy rates. A shorter time interval between repair and TESE favors significantly higher pregnancy rates (pregnant group, time interval: 42.2 ⫾ 8.93 months; and nonpregnant group, time interval: 80.0 ⫾ 12.34 months, P ⬍.05) (Table 3). UROLOGY 75 (1), 2010
Table 2. ICSI cycle characteristics Features of Women in NOA Patients Age (years) FSH (m IU/L) Duration of infertility (years) E2 level on the day of hCG (pg/mL) Total gonadotropin dose (IU) M II oocyte number Fertilization rates (%) No. transferred embryos No. grade 1 embryos Implantation rates (%) Clinical pregnancy rates (%) Live birthrates (%)
NOA With Varicocelectomy (n ⫽ 31)
NOA Without Varicocelectomy (n ⫽ 65)
P
28.74 ⫾ 5.19 6.32 ⫾ 1.77 6.95 ⫾ 4.15 2517.64 ⫾ 976.91 2304 ⫾ 828 12.61 ⫾ 6.04 62.14% ⫾ 16.21% 3.22 ⫾ 0.88 1.74 ⫾ 1.38 40.59% ⫾ 32.64% 74.2% (23/31) 64.5% (20/31)
29.43 ⫾ 3.9 5.47 ⫾ 1.33 7.09 ⫾ 4.49 2423.79 ⫾ 1357.04 2276 ⫾ 1006 13.72 ⫾ 6.41 61.83% ⫾ 20.96% 3.27 ⫾ 0.96 1.40 ⫾ 1.25 26.05% ⫾ 29.83% 52.3% (34/65) 41.5% (27/65)
.47 .642 .43 .732 .892 .453 .941 .298 .232 .033 .033 .029
Table 3. Time interval between varicocele repair and TESE Varicocele Repair Group (n ⫽ 31)
Pregnant Varicocele Repair Subgroup (n ⫽ 23)
Nonpregnant Varicocele Repair Subgroup (n ⫽ 8)
P
42.2 ⫾ 8.93
80.0 ⫾ 12.34
.031
Varicocele repair and TESE time interval (months)
Table 4. ICSI outcomes of NOA patients ICSI Outcomes of NOA Patients Implantation rate (IR) Clinical pregnancy rate (CPR) Live birthrate (LBR)
Fresh TESE With No Fresh TESE With Varicocelectomy Varicocelectomy (n ⫽ 26) (n ⫽ 18)
Frozen-Thawed Sperm With No Varicocelectomy (n ⫽ 39)
Frozen-Thawed Sperm With Varicocelectomy (n ⫽ 13)
P
26.34% 53.8% (14/26)
45.46% 77.8% (14/18)
25.85% 51.3% (20/39)
33.84% 69.2% (9/13)
NS NS
34.6% (9/26)
66.7% (12/18)
46.2% (18/39)
61.5% (8/13)
NS
NS ⫽ not significant.
When compared with subgroups in fresh TESE and frozen-thawed sperm, a history of varicocelectomy might be associated with improved ICSI outcomes, but the differences were not statistically significant (Table 4). A chromosomal assessment was performed in all the NOA patients. Four patients had Klinefelter syndrome (47, XXY), 1 patient had 47 XYY, and 4 patients had AzF c microdeletions. Eighty-seven NOA patients had normal chromosomal karyotypes. In our study group, 9.3% of the patients had genetic abnormalities.
COMMENT The effects of varicocele may often result in generalized impairment of sperm production, characterized by abnormal sperm quality and the fertilizing capacity of the haploid male gamete.7 Varicocelectomy has become the most commonly performed operation for male infertility. The first publication on the importance of varicocelectomy in male infertility was in 1952 by Tulloch,8 who reported spontaneous pregnancy after varicocele repair in an azoospermic man. However, there have been conflicting results on the effect of varicocele repair in small series of azoospermic men.1-9 One study suggested that the UROLOGY 75 (1), 2010
results of varicocele repair in azoospermic men reveal that a certain threshold of spermatogenesis, requiring the presence of at least spermatids, is necessary for effective varicocele repair.10 Pasqualotto et al11 reported that improvement in semen quality after varicocelectomy may be possible even in azoospermic patients who present germ cell aplasia in a single large testis biopsy. The indications for varicocelectomy in men with NOA remain controversial. The data presented herein indicate that implantation rates, clinical pregnancy, and live birth rates were higher in the varicocelectomy group. As this study has shown, varicocele repair has demonstrable benefits for selected azoospermic men. Another important issue highlighted in our study was that the time interval between varicocelectomy and TESE could be explained by the temporary effect of varicocelectomy resulting in the induction of spermatogenesis. According to our study, a shorter time interval between varicocele repair and TESE seems to be associated with higher pregnancy rates. In the pregnant varicocele repair group there was a shorter period, as much as 40 months. Pasqualotto et al11 also reported that recovery of spermatogenesis was transient and that their patients relapsed into azoospermia 6 months after varicocele repair. After 85
the induction of spermatogenesis by varicocele repair, a few sperm would be found in the ejaculate, which avoids patients needing to undergo an invasive procedure. Macro/microsurgical varicocelectomy can be considered an optional treatment modality in selective nonobstructive azoospermic patients with varicocele before intervention with fewer cost-effective and more bothersome assisted reproductive techniques.12 Our study also confirmed that a shorter time interval favors a good prognostic factor for ICSI outcomes in sperm positive NOA patients. Furthermore, our study has shown that varicocele repair might have favorable effects for higher sperm retrieval rate in NOA patients. Karyotype abnormalities or Y-chromosome deletions were detected in 16.6% of azoospermic men.13 There is also sparse literature that addresses the results of varicocelectomy in infertile men who have coexisting genetic infertility. Men with varicocele and genetic lesions appear to have a poorer response to varicocele repair than men without coexisting genetic lesions.14 In our study group with no varicocele repair, there were 4 AzF c microdeletions in patients, both of whom had live births. One of the 4 Klinefelter syndrome patients had negative pregnancy test results while the other 3 had live births and their babies had normal chromosomal karyotypes. Interestingly, 9 patients were excluded from study due to fertilization failure. Two of these 9 patients had AzF c microdeletions and 1 had a 47 XYY chromosomal karyotype. Moreover, 33.3% of patients in whom the embryo transfer was canceled due to fertilization failure had genetic lesions. This is a pilot study and is limited because of the use of retrospective data. In our IVF database, 120 patients were suffering from NOA whose sperm was positive on TESE and this small number was another limitation. Patients suffering from NOA with prior varicocele repair are scarce. Microsurgical varicocele repair should be considered for all men with azoospermia who have a clinically palpable varicocele. This is the first study evaluating the
86
effect of varicocele repair on ICSI outcomes in patients with NOA who were candidates for ICSI. Prospective randomized trials are needed to evaluate the effect of varicocele repair in patients with NOA.
References 1. Czaplicki M, Bablok L, Janczewski Z. Varicocelectomy in patients with azoospermia. Arch Androl. 1979;3:51-55. 2. Matthews GJ, Matthews ED, Goldstein M. Induction of spermatogenesis and achievement of pregnancy after microsurgical varicocelectomy in men with azoospermia and severe oligoasthenospermia. Fertil Steril. 1998;70:71-75. 3. Jow WW, Steckel J, Schlegel PN, et al. Motile sperm in human testis biopsy specimens. J Androl. 1993;14:194-198. 4. Schlegel PN, Kaufmann J. Role of varicocelectomy in men with nonobstructive azoospermia. Fertil Steril. 2004;81(6):1585-1588. 5. Kim ED, Leibman BB, Grinblat DM, et al. Varicocele repair improves semen parameters in azoospermic men with spermatogenic failure. J Urol. 1999;162:737-740. 6. Aboulghar MA, Mansour RT, Serour GI, et al. Fertilization and pregnancy rates after intracytoplasmic sperm injection using ejaculate semen and surgically retrieved sperm. Fertil Steril. 1997;681: 108-111. 7. Sofikitis NV, Miyagawa I, Incze P, et al. Detrimental effect of the left varicocele on the reproductive capacity of the early haploid male gamete. J Urol. 1996;156:267-270. 8. Tulloch WS. Consideration of sterility, subfertility in male. Edinb Med J. 1952;59:29-34. 9. Mehan DJ. Results of ligation of internal spermatic vein in the treatment of infertility in azoospermic patients. Fertil Steril. 1976; 271:110-114. 10. Kadıoglu A, Tefekli A, Cayan S, et al. Microsurgical inguinal varicocele repair in azoospermic men. Urology. 2001;57:328-333. 11. Pasqualotto FF, Lucon AM, Hallak J, et al. Induction of spermatogenesis in azoospermic men after varicocele repair. Hum Reprod. 2003;18:108-112. 12. Lee JS, Park HJ, Seo JT. What is the indication of varicocelectomy in men with nonobstructive azoospermia? Urology. 2007;69(2):352355. 13. Kleiman SE, Yogev L, Gamzu R, et al. Genetic evaluation of infertile men. Hum Reprod. 1999;14(1):33-38. 14. Cayan S, Lee D, Black LD, et al. Response to varicocelectomy in oligospermic men with and without defined genetic infertility. Urology. 2001;57(3):530-535.
UROLOGY 75 (1), 2010
METHODS
RESULTS
CONCLUSIONS
To examine our retrospective data on the outcomes of intracytoplasmic sperm injection (ICSI) and to determine whether a history of varicocele repair in men with nonobstructive azoospermia (NOA) undergoing an ICSI cycle was optimizing or not. This retrospective study was conducted on Baskent University Department of Obstetrics and Gynecology, IVF Unit, and Department of Urology. Infertile couples suffering from NOA scheduled to an ICSI cycle, which was controlled ovarian hyperstimulation with a gonadotropin or gonadotrophin-releasing hormone-agonist protocol, selected for the study were divided into 2 groups: group 1 (n ⫽ 31) included NOA patients who had undergone prior varicocele repair, and group 2 (n ⫽ 65) included NOA patients who had not undergone varicocele repair. There was a significant difference between the 2 groups considering the sperm retrieval rate, which was higher in the varicocele repair group (sperm retrieval rate 60.81% and 38.46% respectively, P ⫽ .01). The clinical pregnancy rate and live birth rate were significantly higher in the varicocelectomy group (74.2% vs 52.3% and 64.5% vs 41.5%, respectively, P ⬍.05). Varicocele repair in NOA might be considered in patients undergoing ICSI cycle. UROLOGY 75: 83– 86, 2010. © 2010 Elsevier Inc.
T
he ability to retrieve sperm from the testes along with the discovery that these spermatozoa are capable of fertilizing an egg and producing a live, healthy offspring by intracytoplasmic sperm injection (ICSI) has changed the reproductive options for azoospermic men. Testicular sperm extraction (TESE) has been used successfully to retrieve sperm directly from seminiferous tubules, and can result in oocyte fertilization when combined with ICSI. Varicocele in association with azoospermia is estimated to range between 5% and 10%, and studies have clearly shown the beneficial effect of varicocele repair in azoospermic cases.1,2 Although these men had no sperm in their ejaculate, it was discovered on testicular biopsy that they often had isolated pockets of sperm production in their testes from which sperm could be retrieved.3 The success rate of varicocele repair in nonobstructive azoospermia (NOA) is still controversial. A history of prior varicocele repair does not seem to affect the chance of sperm retrieval by TESE for men From the Departments of Obstetrics and Gynecology and Urology, Baskent University Faculty of Medicine, Adana, Turkey Reprint requests: Bulent Haydardedeoglu, M.D., Department of Obstetrics and Gynecology, Baskent University Faculty of Medicine, Cemalpasa Mah 5 Sokak Ferah Apt Kat 9 no 18 Seyhan, Adana, Turkey. E-mail: [email protected] Submitted: June 5, 2009, accepted (with revisions): September 9, 2009
© 2010 Elsevier Inc. All Rights Reserved
with clinical varicoceles and NOA.4 However, after varicocele repair, one study found a return of sperm to the ejaculate in 12 of 28 (43%) men with NOA at an average follow-up of 24 months.5 Furthermore, motile sperm in the ejaculate of azoospermic patients yields superior ICSI success rates compared with sperm obtained by TESE.6 Thereby, varicocele repair in completely azoospermic men has also prompted investigators to determine the effect of this procedure on spermatogenesis in NOA. The effect of varicocelectomy in NOA on ICSI outcomes has not been evaluated in the literature. Thus, our aim was to examine our retrospective data on ICSI outcomes to determine whether a history of varicocele repair in men with NOA undergoing an ICSI cycle was optimizing or not.
MATERIAL AND METHODS This study was conducted from November 2003 to April 2008 in the Division of Reproductive and Endocrinology Unit, Department of Gynecology and Obstetrics, and Department of Urology, at Baskent University. Microdissection TESE had been applied to 269 NOA patients. The number of NOA patients with previous macrosurgical varicocelectomy operation was 74 and the number of NOA patients without varicocelectomy surgery was 195. In total, 120 TESE patients diagnosed 0090-4295/10/$34.00 doi:10.1016/j.urology.2009.09.023
83
with NOA were eligible to participate in the ICSI program for this study. Patients who had undergone an ICSI cycle with a long-luteal gonadotrophin-releasing hormone (GnRH) agonist protocol were selected to obtain uniform data and to minimize the female factor. Nine patients undergoing a long-luteal GnRH agonist protocol were excluded from the study due to the cancelation of embryo transfer because of fertilization failure. Microdose flare and GnRH antagonist protocols were omitted from the study, which included 15 patients diagnosed as poor responders (⬍6 oocytes in the ovum pick up) and potential poor responders (follicle-stimulating hormone ⬎10 mIU/L and antral follicle count ⬍6). Thereby, the first cycles of 96 patients were included in our study. According to our clinical policy, patients suffering from NOA who were going to undergo an ICSI cycle were offered fresh TESE during oocyte retrieval or cryopreservation of a sperm sample and survival after thawing was checked. In the cryopreservation group, TESE was performed for freezing 3 months before oocyte retrieval. Patients from whom sperm was not obtained by TESE and those from whom sperm was obtained from their ejaculate were excluded from the study. Previous varicocelectomy was determined from each patient’s anamnesis and their operation notes. The severity, localization, and operation time of varicocele repair were recorded. All varicocele repair patients had been operated on due to grade 3 varicocele. Operations for grade 1 and grade 2 varicocele had not been performed, but there was no varicocele in all patients with NOA in the study group, which was diagnosed by the Doppler ultrasonography. All varicocelectomy operations were macrosurgical varicocelectomy which were recorded from their operation notes. After 6 months of varicocele repair, all NOA patients’ sperm analyses were assessed on at least 3 spermiograms to put correct diagnosis of azoospermia. Microdissection TESE was performed by making a 3- to 4-cm incision in the tunica albuginea under operating microscopy, avoiding the underlying testicular artery. Seminiferous tubules that appeared dilated and opaque were harvested. Before the microdissection TESE operation, a chromosomal assessment was performed in all NOA patients. The patients selected for the study were divided into 2 groups: group 1 (n ⫽ 31) included NOA patients who had undergone prior varicocele repair, and group 2 (n ⫽ 65) included NOA patients who had not undergone varicocele repair. Fourteen NOA patients in the varicocele repair group and 10 NOA patients in group 2 were omitted from the study due to their poor responder spouse. Ovarian downregulation was initiated with daily leuprolide acetate 1 mg (Lucrin, Abbott, France), beginning on the 21st day of the preceding menstruation. After ovarian suppression was achieved, the dose was reduced to 0.5 mg until the day of human chorionic gonadotropin (hCG). If there were no cysts ⱖ 2 cm and the E2 was ⬍50 pg/mL, gonadotropin stimulation with 150-300 IUs of gonadotropins (Gonal-F, Serono, Randolph, MA) was performed, with E2 monitoring commencing on the morning of stimulation day 5. Ultrasound and blood E2 monitoring continued until hCG administration criteria were met with at least 3 follicles having a maximum diameter of ⬎17 mm. Transvaginal ultrasound-guided oocyte retrieval was performed 35-36 hours after the hCG injection. Oocyte pick-up was performed with a 17-gauge needle for oocyte retrieval under sedation with propofol (propofol 1% Fresenius Kabi, Germany). The oocyte-corona complexes were denuded, and ICSI was performed after 2 hours of incubation and the embryos were 84
Table 1. The basal characteristics of men with NOA NOA With Varicocelectomy (n ⫽ 74) Age (y) FSH (mIU/L) Testis volume Sperm retrieval rate (%)
NOA Without Varicocelectomy (n ⫽ 195)
35.06 ⫾ 6.40 35.20 ⫾ 6.09 16.73 ⫾ 13.65 17.89 ⫾ 12.24 14.35 ⫾ 6.7 13.66 ⫾ 6.82 60.8% (45/74) 38.46% (75/195)
P NS NS NS .01
NS ⫽ not significant.
transferred on day 3. The embryo transfer policy depends on the number and quality of embryos developed. The transfer protocol was individualized for a maximum of 4 poor grade embryos. All patients received luteal support with 90 mg progesterone intravaginally (Crinone 8% gel, Serono, Randolph, MA) daily after embryo transfer. Clinical pregnancy was defined as the presence of at least 1 gestational sac with detectable fetal cardiac activity by transvaginal ultrasonography. Live birth was defined as delivery time after 27 weeks of gestation with at least 1 live baby.
Statistical Analysis Data are expressed as means ⫾ SD. The baseline differences between the 3 groups were analyzed by one-way analysis of variance. In contingency tables, the chi-square test or the two-sided Fisher exact test was performed. A value of P less than .05 was considered statistically significant. The data were analyzed using SPSS for Windows (version 11.0; SPSS, Inc., Chicago, IL).
RESULTS Microdissection TESE had been applied to 269 NOA patients whose sperm retrieval rate was 44.9%. There was a significant difference between the 2 groups in consideration with the sperm retrieval rate which was higher in the varicocele repair group (sperm retrieval rate 60.81% and 38.46% respectively, P ⫽ .01) (Table 1). The basal characteristics of the 2 groups of NOA patients were similar (Table 1). The ICSI cycle characteristics are shown in Table 2. There was no significant difference between NOA patients with varicocelectomy and the group that did not undergo surgery in consideration with the ICSI cycle characteristics. However, implantation rates, clinical pregnancy rate, and live birth rate were significantly higher in the varicocelectomy group (40.59 ⫾ 32.64% vs 26.05 ⫾ 29.83%, 74.2% vs 52.3%, and 64.5% vs 41.5%, respectively, P ⬍.05) (Table 2). Grade 1 embryo numbers seemed to be superior in the varicocelectomy group, but the differences were not statistically significant (1.74% vs 1.4%, P ⬎.05) (Table 2). We compared the time interval between varicocele repair and TESE considering clinical pregnancy rates. A shorter time interval between repair and TESE favors significantly higher pregnancy rates (pregnant group, time interval: 42.2 ⫾ 8.93 months; and nonpregnant group, time interval: 80.0 ⫾ 12.34 months, P ⬍.05) (Table 3). UROLOGY 75 (1), 2010
Table 2. ICSI cycle characteristics Features of Women in NOA Patients Age (years) FSH (m IU/L) Duration of infertility (years) E2 level on the day of hCG (pg/mL) Total gonadotropin dose (IU) M II oocyte number Fertilization rates (%) No. transferred embryos No. grade 1 embryos Implantation rates (%) Clinical pregnancy rates (%) Live birthrates (%)
NOA With Varicocelectomy (n ⫽ 31)
NOA Without Varicocelectomy (n ⫽ 65)
P
28.74 ⫾ 5.19 6.32 ⫾ 1.77 6.95 ⫾ 4.15 2517.64 ⫾ 976.91 2304 ⫾ 828 12.61 ⫾ 6.04 62.14% ⫾ 16.21% 3.22 ⫾ 0.88 1.74 ⫾ 1.38 40.59% ⫾ 32.64% 74.2% (23/31) 64.5% (20/31)
29.43 ⫾ 3.9 5.47 ⫾ 1.33 7.09 ⫾ 4.49 2423.79 ⫾ 1357.04 2276 ⫾ 1006 13.72 ⫾ 6.41 61.83% ⫾ 20.96% 3.27 ⫾ 0.96 1.40 ⫾ 1.25 26.05% ⫾ 29.83% 52.3% (34/65) 41.5% (27/65)
.47 .642 .43 .732 .892 .453 .941 .298 .232 .033 .033 .029
Table 3. Time interval between varicocele repair and TESE Varicocele Repair Group (n ⫽ 31)
Pregnant Varicocele Repair Subgroup (n ⫽ 23)
Nonpregnant Varicocele Repair Subgroup (n ⫽ 8)
P
42.2 ⫾ 8.93
80.0 ⫾ 12.34
.031
Varicocele repair and TESE time interval (months)
Table 4. ICSI outcomes of NOA patients ICSI Outcomes of NOA Patients Implantation rate (IR) Clinical pregnancy rate (CPR) Live birthrate (LBR)
Fresh TESE With No Fresh TESE With Varicocelectomy Varicocelectomy (n ⫽ 26) (n ⫽ 18)
Frozen-Thawed Sperm With No Varicocelectomy (n ⫽ 39)
Frozen-Thawed Sperm With Varicocelectomy (n ⫽ 13)
P
26.34% 53.8% (14/26)
45.46% 77.8% (14/18)
25.85% 51.3% (20/39)
33.84% 69.2% (9/13)
NS NS
34.6% (9/26)
66.7% (12/18)
46.2% (18/39)
61.5% (8/13)
NS
NS ⫽ not significant.
When compared with subgroups in fresh TESE and frozen-thawed sperm, a history of varicocelectomy might be associated with improved ICSI outcomes, but the differences were not statistically significant (Table 4). A chromosomal assessment was performed in all the NOA patients. Four patients had Klinefelter syndrome (47, XXY), 1 patient had 47 XYY, and 4 patients had AzF c microdeletions. Eighty-seven NOA patients had normal chromosomal karyotypes. In our study group, 9.3% of the patients had genetic abnormalities.
COMMENT The effects of varicocele may often result in generalized impairment of sperm production, characterized by abnormal sperm quality and the fertilizing capacity of the haploid male gamete.7 Varicocelectomy has become the most commonly performed operation for male infertility. The first publication on the importance of varicocelectomy in male infertility was in 1952 by Tulloch,8 who reported spontaneous pregnancy after varicocele repair in an azoospermic man. However, there have been conflicting results on the effect of varicocele repair in small series of azoospermic men.1-9 One study suggested that the UROLOGY 75 (1), 2010
results of varicocele repair in azoospermic men reveal that a certain threshold of spermatogenesis, requiring the presence of at least spermatids, is necessary for effective varicocele repair.10 Pasqualotto et al11 reported that improvement in semen quality after varicocelectomy may be possible even in azoospermic patients who present germ cell aplasia in a single large testis biopsy. The indications for varicocelectomy in men with NOA remain controversial. The data presented herein indicate that implantation rates, clinical pregnancy, and live birth rates were higher in the varicocelectomy group. As this study has shown, varicocele repair has demonstrable benefits for selected azoospermic men. Another important issue highlighted in our study was that the time interval between varicocelectomy and TESE could be explained by the temporary effect of varicocelectomy resulting in the induction of spermatogenesis. According to our study, a shorter time interval between varicocele repair and TESE seems to be associated with higher pregnancy rates. In the pregnant varicocele repair group there was a shorter period, as much as 40 months. Pasqualotto et al11 also reported that recovery of spermatogenesis was transient and that their patients relapsed into azoospermia 6 months after varicocele repair. After 85
the induction of spermatogenesis by varicocele repair, a few sperm would be found in the ejaculate, which avoids patients needing to undergo an invasive procedure. Macro/microsurgical varicocelectomy can be considered an optional treatment modality in selective nonobstructive azoospermic patients with varicocele before intervention with fewer cost-effective and more bothersome assisted reproductive techniques.12 Our study also confirmed that a shorter time interval favors a good prognostic factor for ICSI outcomes in sperm positive NOA patients. Furthermore, our study has shown that varicocele repair might have favorable effects for higher sperm retrieval rate in NOA patients. Karyotype abnormalities or Y-chromosome deletions were detected in 16.6% of azoospermic men.13 There is also sparse literature that addresses the results of varicocelectomy in infertile men who have coexisting genetic infertility. Men with varicocele and genetic lesions appear to have a poorer response to varicocele repair than men without coexisting genetic lesions.14 In our study group with no varicocele repair, there were 4 AzF c microdeletions in patients, both of whom had live births. One of the 4 Klinefelter syndrome patients had negative pregnancy test results while the other 3 had live births and their babies had normal chromosomal karyotypes. Interestingly, 9 patients were excluded from study due to fertilization failure. Two of these 9 patients had AzF c microdeletions and 1 had a 47 XYY chromosomal karyotype. Moreover, 33.3% of patients in whom the embryo transfer was canceled due to fertilization failure had genetic lesions. This is a pilot study and is limited because of the use of retrospective data. In our IVF database, 120 patients were suffering from NOA whose sperm was positive on TESE and this small number was another limitation. Patients suffering from NOA with prior varicocele repair are scarce. Microsurgical varicocele repair should be considered for all men with azoospermia who have a clinically palpable varicocele. This is the first study evaluating the
86
effect of varicocele repair on ICSI outcomes in patients with NOA who were candidates for ICSI. Prospective randomized trials are needed to evaluate the effect of varicocele repair in patients with NOA.
References 1. Czaplicki M, Bablok L, Janczewski Z. Varicocelectomy in patients with azoospermia. Arch Androl. 1979;3:51-55. 2. Matthews GJ, Matthews ED, Goldstein M. Induction of spermatogenesis and achievement of pregnancy after microsurgical varicocelectomy in men with azoospermia and severe oligoasthenospermia. Fertil Steril. 1998;70:71-75. 3. Jow WW, Steckel J, Schlegel PN, et al. Motile sperm in human testis biopsy specimens. J Androl. 1993;14:194-198. 4. Schlegel PN, Kaufmann J. Role of varicocelectomy in men with nonobstructive azoospermia. Fertil Steril. 2004;81(6):1585-1588. 5. Kim ED, Leibman BB, Grinblat DM, et al. Varicocele repair improves semen parameters in azoospermic men with spermatogenic failure. J Urol. 1999;162:737-740. 6. Aboulghar MA, Mansour RT, Serour GI, et al. Fertilization and pregnancy rates after intracytoplasmic sperm injection using ejaculate semen and surgically retrieved sperm. Fertil Steril. 1997;681: 108-111. 7. Sofikitis NV, Miyagawa I, Incze P, et al. Detrimental effect of the left varicocele on the reproductive capacity of the early haploid male gamete. J Urol. 1996;156:267-270. 8. Tulloch WS. Consideration of sterility, subfertility in male. Edinb Med J. 1952;59:29-34. 9. Mehan DJ. Results of ligation of internal spermatic vein in the treatment of infertility in azoospermic patients. Fertil Steril. 1976; 271:110-114. 10. Kadıoglu A, Tefekli A, Cayan S, et al. Microsurgical inguinal varicocele repair in azoospermic men. Urology. 2001;57:328-333. 11. Pasqualotto FF, Lucon AM, Hallak J, et al. Induction of spermatogenesis in azoospermic men after varicocele repair. Hum Reprod. 2003;18:108-112. 12. Lee JS, Park HJ, Seo JT. What is the indication of varicocelectomy in men with nonobstructive azoospermia? Urology. 2007;69(2):352355. 13. Kleiman SE, Yogev L, Gamzu R, et al. Genetic evaluation of infertile men. Hum Reprod. 1999;14(1):33-38. 14. Cayan S, Lee D, Black LD, et al. Response to varicocelectomy in oligospermic men with and without defined genetic infertility. Urology. 2001;57(3):530-535.
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