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Should a Varicocele Be Repaired in Non-infertile Patients with Hypogonadism?

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Varicocele and Male Infertility

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Abstract

Varicocele is a common condition that has been traditionally linked to impaired spermatogenesis and infertility. More recently, however, there is a growing evidence that varicocele may also jeopardize Leydig cell function with consequential impairment of testosterone biosynthesis and hypogonadism, which could be reversed with varicocelectomy. The pathophysiology of varicocele-induced Leydig cell ultrastructural and functional alterations and impaired steroidogenesis is still illusive, and several mechanisms have been proposed. While testicular hyperthermia theory prevails, the pathophysiology is more likely multifactorial.

Several contemporary studies confirmed improvements of androgen levels after repair of varicocele which were found to be inversely correlating to baseline serum testosterone levels, with higher response in baseline hypogonadal men compared to eugonadals.

Very few studies have examined the association between varicocele and hypogonadism symptoms, such as erectile dysfunction (ED), hypoactive sexual drive, as well as premature ejaculation (PE), to report improvements of these sexual functions after varicocelectomy. However, these studies have several flaws and the hypothesis of improvement of sexual symptoms after varicocelectomy is still lacking good evidence.

The majority of studies supporting varicocele-hypogonadism relationship have primarily focused on infertile men, while evidence addressing varicocele-hypogonadism linkage among fertile men is still lacking. Thus, proposing varicocelectomy as a treatment of biochemical or symptomatic hypogonadism among fertile men should not be considered as a standard of care in the routine practice and should be only contemplated on an experimental basis.

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References

  1. Masson P, Brannigan RE. The varicocele. Urol Clin North Am. 2014;41(1):129–44.

    Article  PubMed  Google Scholar 

  2. Meacham RB, Townsend RR, Rademacher D, Drose JA. The incidence of varicoceles in the general population when evaluated by physical examination, gray scale sonography and color Doppler sonography. J Urol. 1994;151:1535–8.

    Article  CAS  PubMed  Google Scholar 

  3. The influence of varicocele on parameters of fertility in a large group of men presenting in infertility clinics. World Health Organization. Fertil Steril. 1992;57:1289–93.

    Article  Google Scholar 

  4. Gat Y, Bachar GN, Zukerman Z, et al. Varicocele: a bilateral disease. Fertil Steril. 2004;81:424–9.

    Article  PubMed  Google Scholar 

  5. Raman JD, Walmsley K, Goldstein M. Inheritance of varicoceles. Urology. 2005;65:1186–9.

    Article  PubMed  Google Scholar 

  6. Schlegel PN, Goldstein M. Alternate indications for varicocele repair: non-obstructive azoospermia, pain, androgen deficiency and progressive testicular dysfunction. Fertil Steril. 2011;96(6):1288–93.

    Article  PubMed  Google Scholar 

  7. Hayden RP, Tanrikut C. Testosterone and Varicocele. Urol Clin North Am. 2016;43(2):223–32.

    Article  PubMed  Google Scholar 

  8. Kim KH, Lee JY, Kang DH, Lee H, Seo JT, et al. Impact of surgical varicocele repair on pregnancy rate in subfertile men with clinical varicocele and impaired semen quality: a meta-analysis of randomized clinical trials. Korean J Urol. 2013;54:703–9.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Agarwal A, Deepinder F, Cocuzza M, et al. Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology. 2007;70:532–8.

    Article  PubMed  Google Scholar 

  10. Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM. Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial. Eur Urol. 2011;59:455–61.

    Article  PubMed  Google Scholar 

  11. Ficarra V, Cerruto MA, Liguori G, et al. Treatment of varicocele in subfertile men: the Cochrane review—a contrary opinion. Eur Urol. 2006;49:258–63.

    Article  PubMed  Google Scholar 

  12. Goldstein M, Gilbert BR, Dicker AP, et al. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol. 1992;148:1808–11.

    Article  CAS  PubMed  Google Scholar 

  13. Li F, Yue H, Yamaguchi K, et al. Effect of surgical repair on testosterone production in infertile men with varicocele: a meta-analysis. Int J Urol. 2012;19(2):149–54.

    Article  CAS  PubMed  Google Scholar 

  14. Chen X, Yang D, Lin G, Bao J, Wang J, Tan W. Efficacy of varicocelectomy in the treatment of hypogonadism in subfertile males with clinical varicocele: a meta-analysis. Andrologia. 2017;49(10).

    Article  Google Scholar 

  15. Pastuszak AW, Wang R. Varicocele and testicular function. Asian J Androl. 2015;17(4):659–67.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Dahl EV, Herrick JF. A vascular mechanism for maintaining testicular temperature by counter-current exchange. Surg Gynecol Obstet. 1959;108:697–705.

    CAS  PubMed  Google Scholar 

  17. Zorgniotti AW, Macleod J. Studies in temperature, human semen quality, and varicocele. Fertil Steril. 1973;24:854–63.

    Article  CAS  PubMed  Google Scholar 

  18. Mieusset R, Bujan L, Mondinat C, Mansat A, Pontonnier F, et al. Association of scrotal hyperthermia with impaired spermatogenesis in infertile men. Fertil Steril. 1987;48:1006–11.

    Article  CAS  PubMed  Google Scholar 

  19. Goldstein M, Eid JF. Elevation of intratesticular and scrotal skin surface temperature in men with varicocele. J Urol. 1989;142:743–5.

    Article  CAS  PubMed  Google Scholar 

  20. Yin Y, Hawkins KL, DeWolf WC, Morgentaler A. Heat stress causes testicular germ cell apoptosis in adult mice. J Androl. 1997;18:159–65.

    CAS  PubMed  Google Scholar 

  21. Shiraishi K, Takihara H, Matsuyama H. Elevated scrotal temperature, but not varicocele grade, reflects testicular oxidative stress-mediated apoptosis. World J Urol. 2010;28:359–64.

    Article  CAS  PubMed  Google Scholar 

  22. Hassanin AM, Ahmed HH, Kaddah AN. A global view of the pathophysiology of varicocele. Andrology. 2018;6:654. https://doi.org/10.1111/andr.12511. [Epub ahead of print.

    Article  CAS  PubMed  Google Scholar 

  23. Allamaneni SS, Naughton CK, Sharma RK, Thomas AJ Jr, Agarwal A. Increased seminal reactive oxygen species levels in patients with varicoceles correlate with varicocele grade but not with testis size. Fertil Steril. 2004;82:1684–6.

    Article  PubMed  Google Scholar 

  24. Hendin BN, Kolettis PN, Sharma RK, Thomas AJ Jr, Agarwal A. Varicocele is associated with elevated spermatozoal reactive oxygen species production and diminished seminal plasma antioxidant capacity. J Urol. 1999;161:1831–4.

    Article  CAS  PubMed  Google Scholar 

  25. Gilbert BR, Witkin SS, Goldstein M. Correlation of sperm-bound immunoglobulins with impaired semen analysis in infertile men with varicoceles. Fertil Steril. 1989;52:469–73.

    Article  CAS  PubMed  Google Scholar 

  26. Fujisawa M, Yoshida S, Matsumoto O, Kojima K, Kamidono S. Deoxyribonucleic acid polymerase activity in the testes of infertile men with varicocele. Fertil Steril. 1988;50:795–800.

    Article  CAS  PubMed  Google Scholar 

  27. Simsek F, Turkeri L, Cevik I, Bircan K, Akdas A. Role of apoptosis in testicular tissue damage caused by varicocele. Arch Esp Urol. 1998;51:947–50.

    CAS  PubMed  Google Scholar 

  28. Ando S, Giacchetto C, Colpi G, et al. Physiopathologic aspects of Leydig cell function in varicocele patients. J Androl. 1984;5(3):163–70.

    Article  CAS  PubMed  Google Scholar 

  29. Ando S, Giacchetto C, Beraldi E, et al. Progesterone, 17-OH-progesterone, androstenedione and testosterone plasma levels in spermatic venous blood of normal men and varicocele patients. Horm Metab Res. 1985;17(2):99–103.

    Article  CAS  PubMed  Google Scholar 

  30. Scholler R, Nahoul K, Castanier M, et al. Testicular secretion of conjugated and unconjugated steroids in normal adults and in patients with varicocele. Baseline levels and time-course response to hCG administration. J Steroid Biochem. 1984;20(1):203–15.

    Article  CAS  PubMed  Google Scholar 

  31. Sirvent JJ, Bernat R, Navarro MA, Rodriguez Tolra J, Guspi R, et al. Leydig cell in idiopathic varicocele. Eur Urol. 1990;17:257–61.

    Article  CAS  PubMed  Google Scholar 

  32. Francavilla S, Bruno B, Martini M, et al. Quantitative evaluation of Leydig cells in testicular biopsies of men with varicocele. Arch Androl. 1986;16(2):111–7.

    Article  CAS  PubMed  Google Scholar 

  33. Weiss DB, Rodrigues-Rigau L, Smith KD, et al. Leydig cell density and function and their relation to gonadotropins in infertile oligospermic men with varicocele. Isr J Med Sci. 1979;15(7):556–63.

    CAS  PubMed  Google Scholar 

  34. Rajfer J, Turner TT, Rivera F, et al. Inhibition of testicular testosterone biosynthesis following experimental varicocele in rats. Biol Reprod. 1987;36(4):933–7.

    Article  CAS  PubMed  Google Scholar 

  35. Zheng Y, Zhang X, Zhou J, et al. Effects on the ipsilateral testis during progression of experimental varicocele in rat. Med Sci Monit. 2008;14(6):BR122–6.

    PubMed  Google Scholar 

  36. Ozturk MI, Koca O, Keles MO, et al. The impact of unilateral experimental rat varicocele model on testicular histopathology, Leydig cell counts, and intratesticular testosterone levels of both testes. Urol J. 2013;10(3):973–80.

    PubMed  Google Scholar 

  37. Shafik A, Wali MA, Abdel Azis YE, et al. Experimental model of varicocele. Eur Urol. 1989; 16(4):298–303.

    Article  CAS  PubMed  Google Scholar 

  38. Ghosh PK, York JP. Changes in testicular testosterone and acid and alkaline phosphatase activity in testis and accessory sex organs after induction of varicocele in noble rats. J Surg Res. 1994;56(3):271–6.

    Article  CAS  PubMed  Google Scholar 

  39. Luo D-Y, Yang G, Liu J-J, et al. Effects of varicocele on testosterone, apoptosis and expression of StAR mRNA in rat Leydig cells. Asian J Androl. 2011;13(2):287–91.

    Article  CAS  PubMed  Google Scholar 

  40. Diemer T, Allen JA, Hales KH, et al. Reactive oxygen disrupts mitochondria in MA-10 tumor Leydig cells and inhibits steroidogenic acute regulatory (StAR) protein and steroidogenesis. Endocrinology. 2003;144(7):2882–91.

    Article  CAS  PubMed  Google Scholar 

  41. Rodriguez-Rigau LJ, Weiss DB, Zukerman Z, et al. A possible mechanism for the detrimental effect of varicocele on testicular function in man. Fertil Steril. 1978;30(5):577–85.

    Article  CAS  PubMed  Google Scholar 

  42. Shabana W, Teleb M, Dawod T, et al. Predictors of improvement in semen parameters after varicocelectomy for male subfertility: a prospective study. Can Urol Assoc J. 2015;9(9–10):E579–82.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Hudson RW, Perez-Marrero RA, Crawford VA, et al. Hormonal parameters of men with varicoceles before and after varicocelectomy. Fertil Steril. 1985;43(6):905–10.

    Article  CAS  PubMed  Google Scholar 

  44. Sweeney TE, Rozum JS, Gore RW. Alteration of testicular microvascular pressures during venous pressure elevation. Am J Phys. 1995;269(1):H37–45.

    CAS  Google Scholar 

  45. Pasqualini T, Chemes H, Coco R, et al. Testicular function in varicocele. Int J Androl. 1980;3(6):679–91.

    Article  CAS  PubMed  Google Scholar 

  46. Stocco DM, Wells J, Clark BJ. The effects of hydrogen peroxide on steroidogenesis in mouse Leydig tumor cells. Endocrinology. 1993;133(6):2827–32.

    Article  CAS  PubMed  Google Scholar 

  47. Pirke KM, Vogt HJ, Sintermann R, et al. Testosterone in peripheral plasma, spermatic vein and in testicular tissue under basal conditions and after HCG stimulation in patients with varicocele. Andrologia. 1983;15(6):637–41.

    Article  CAS  PubMed  Google Scholar 

  48. Comhaire F, Vermeulen A. Plasma testosterone in patients with varicocele and sexual inadequacy. J Clin Endocrinol Metab. 1975;40:824–9.

    Article  CAS  PubMed  Google Scholar 

  49. Mehta A, Goldstein M. Microsurgical varicocelectomy: a review. Asian J Androl. 2013;15:56–60.

    Article  PubMed  Google Scholar 

  50. Andó S, Giacchetto C, Beraldi E, Panno ML, Carpino A, et al. Testosterone and dihydrotestosterone seminal plasma levels in varicocele patients. Andrologia. 1983;15:374–9.

    Article  PubMed  Google Scholar 

  51. Younes AK. Low plasma testosterone in varicocele patients with impotence and male infertility. Arch Androl. 2000;45:187–95.

    Article  CAS  PubMed  Google Scholar 

  52. Hudson RW, Hayes KA, Crawford VA, McKay DE. Seminal plasma testosterone and dihydrotestosterone levels in men with varicoceles. Int J Androl. 1983;6:135–42.

    Article  CAS  PubMed  Google Scholar 

  53. Swerdloff RS, Walsh PC. Pituitary and gonadal hormones in patients with varicocele. Fertil Steril. 1975;26:1006–12.

    Article  CAS  PubMed  Google Scholar 

  54. Su LM, Goldstein M, Schlegel PN. The effect of varicocelectomy on serum testosterone levels in infertile men with varicoceles. J Urol. 1995;154:1752–5.

    Article  CAS  PubMed  Google Scholar 

  55. Tanrikut C, Choi J, Lee R, Benjamin J, Mulhall J, et al. Varicocele is a risk factor for androgen deficiency. Fertil Steril. 2007;88:S386.

    Google Scholar 

  56. Tanrikut C, Goldstein M, Rosoff JS, Lee RK, Nelson CJ, et al. Varicocele as a risk factor for androgen deficiency and effect of repair. BJU Int. 2011;108:1480–4.

    Article  CAS  PubMed  Google Scholar 

  57. Hsiao W, Rosoff JS, Pale JR, Greenwood EA, Goldstein M. Older age is associated with similar improvements in semen parameters and testosterone after subinguinal microsurgical varicocelectomy. J Urol. 2011;185:620–5.

    Article  PubMed  Google Scholar 

  58. Hsiao W, Rosoff JS, Pale JR, Powell JL, Goldstein M. Varicocelectomy is associated with increases in serum testosterone independent of clinical grade. Urology. 2013;81:1213–7.

    Article  PubMed  Google Scholar 

  59. Di Bisceglie C, Bertagna A, Baldi M, Lanfranco F, Tagliabue M, et al. Varicocele sclerotherapy improves serum inhibin B levels and seminal parameters. Int J Androl. 2007;30:531–6.

    Article  PubMed  Google Scholar 

  60. Abdel-Meguid TA, Farsi HM, Al-Sayyad A, Tayib A, Mosli HA, et al. Effects of varicocele on serum testosterone and changes of testosterone after varicocelectomy: a prospective controlled study. Urology. 2014;84:1081–7.

    Article  PubMed  Google Scholar 

  61. Ahmed A, Abdel-Aziz A, Maarouf A, et al. The impact of varicocelectomy on premature ejaculation in varicocele patients. Andrologia. 2015;47(3):276–81.

    Article  PubMed  Google Scholar 

  62. Pierik FH, Abdesselam SA, Vreeburg JT, et al. Increased serum inhibin B levels after varicocele treatment. Clin Endocrinol. 2001;54(6):775–80.

    Article  CAS  Google Scholar 

  63. Rodriguez Peña M, Alescio L, Russell A, et al. Predictors of improved seminal parameters and fertility after varicocele repair in young adults. Andrologia. 2009;41(5):277–81.

    Article  PubMed  Google Scholar 

  64. Resorlu B, Kara C, Sahin E, et al. The significance of age on success of surgery for patients with varicocele. Int Urol Nephrol. 2010;42(2):351–6.

    Article  PubMed  Google Scholar 

  65. Younes AK. Improvement of sexual activity, pregnancy rate, and low plasma testosterone after bilateral varicocelectomy in impotence and male infertility patients. Arch Androl. 2003;49:219–28.

    Article  CAS  PubMed  Google Scholar 

  66. Zohdy W, Ghazi S, Arafa M. Impact of varicocelectomy on gonadal and erectile functions in men with hypogonadism and infertility. J Sex Med. 2011;8:885–93.

    Article  CAS  PubMed  Google Scholar 

  67. Sathya Srini V, Belur Veerachari S. Does varicocelectomy improve gonadal function in men with hypogonadism and infertility? Analysis of a prospective study. Int J Endocrinol. 2011;2011:916380.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Najari BB, Introna L, Paduch DA. Improvements in patient reported sexual function after microsurgical varicocelectomy. Urology. 2016;16:30194–7.

    Google Scholar 

  69. Lotti F, Corona G, Mancini M, et al. The association between varicocele, premature ejaculation and prostatitis symptoms: possible mechanisms. J Sex Med. 2009;6:2878–87.

    Article  CAS  PubMed  Google Scholar 

  70. Wan X, Wang H, Ji Z. Microsurgical varicocelectomy for clinical varicocele: a review for potential new indications. Andrologia. 2017;49:e12827.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Urology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

    Taha Abo-Almagd Abdel-Meguid Hamoda

  2. Department of Urology, Faculty of Medicine, Minia University, El-Minia, Egypt

    Taha Abo-Almagd Abdel-Meguid Hamoda

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  1. Taha Abo-Almagd Abdel-Meguid Hamoda
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Correspondence to Taha Abo-Almagd Abdel-Meguid Hamoda .

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Editors and Affiliations

  1. ANDROFERT, Andrology & Human Reproduction Clinic, Campinas, São Paulo, Brazil

    Sandro C Esteves

  2. S.H. Ho Urology Centre, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong

    Chak-Lam Cho

  3. Department of Urology, Hamad Medical Corporation, Weill Cornell Medicine Qatar, Doha, Qatar

    Ahmad Majzoub

  4. Department of Urology, Cleveland Clinic, Cleveland, OH, USA

    Ashok Agarwal

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Hamoda, T.AA.AM. (2019). Should a Varicocele Be Repaired in Non-infertile Patients with Hypogonadism?. In: Esteves, S., Cho, CL., Majzoub, A., Agarwal, A. (eds) Varicocele and Male Infertility. Springer, Cham. https://doi.org/10.1007/978-3-319-79102-9_38

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