Терапевтический архив (Oct 2012)
Current approach to therapy for male infertility in patients with varicocele
Abstract
Aim. To improve the results of treatment for male infertility in patients with varicocele and to evaluate the efficiency of microsurgical varicocelectomy performed by the same surgeon in a large group of patients. Subjects and methods. 1127 infertile males aged 22 to 52 years (mean 29.6±9.2 years) with varicocele were examined. An analysis of the patients' presenting complaints, collection of history data, examinations, spermogram studies, mixed agglutination reaction (MAR) test, ultrasonography and Doppler study of the scrotum, estimation of blood hormone and inhibin B levels, and genetic studies (karyotype, azoospermia factor (AZF), cystic fibrosis gene) were done. The analysis excluded 193 patients with other causes of infertility. 728 patients underwent uni- and bilateral microsurgical subinguinal varicocelectomy according to the Marmar procedure modified by the authors, 107 had spermatogenesis stimulation (clomiphene citrate, vitamins A and E, selenium, L-carnitine, pentoxifylline, antioxidants) for 3-6 months; 56 patients were untreated. The follow-up period was 3-12 months depending on the efficiency of treatment. Control examination was made every 3 months. Results. After microsurgical varicocelectomy, there were increases in the concentration of spermatozoa from 8.8±7.2 to 23.2±7.9 mln/ml and their active motility from 7.2±5.4 to 31.2±5.2% (category A); the proportion of abnormal sperm forms (Kruger morphology) reduced from 95.4±5 to 87.8±8.3%. The patients with azoospermia (n=39), spermatozoa appeared in 46.2% of cases; 52.8% of the patients with complete teratozoospermia (n=36) exhibited morphologically normal sperm postoperatively (unlike the results of treatment in the comparison groups). Higher sperm concentrations were observed after both microsurgical varicocele and empirical stimulation of spermatogenesis in 69.9 and 29.9% of the patients, respectively. Spontaneous conception occurred in the partners of 47.1% of the males after microsurgical varicocele, 21.5% of those after drug stimulation, and 3.6% of those untreated. Conclusion. Microsurgical varicocele is the most effective and safe treatment option for male infertility in patients with varicocele. Its effect far exceeds the results of drug stimulation of spermatogenesis and those of the follow-up. It lies in a rapid and significant improvement in spermatogenic parameters just 3-6 months after surgery and further continues to increase. This gives rise to spontaneous pregnancy in about 50% of the infertile couples within a year postsurgery. Microsurgical varicocele may be recommended not only as the gold standard surgical treatment for varicocele, but also for the therapy of male infertility in these patients. At the same time, prior to surgical treatment for varicocele, one should rule out all other causes of male infertility and female factor (particularly tubal one).
