Varicocele is present in approximately 15% of men, being one of the most well known diagnosed causes of male infertility 1,2. Various mechanisms were suggested to account for the testicular dysfunction and negative impact on semen parameters associated with varicocele, for example, hyperthermia, retrograde flow of toxic metabolites, venous stasis with hypoxia, alterations in the hypothalamic–pituitary–gonadal axis, and increased oxidative stress 3–7.
The negative impact of varicocele on testicular size had been shown decades ago in both adolescents and adult males depending on its clinical grade 8–11. Zini et al. 12 showed that clinical left varicocele can negatively impact left testicular size and that subclinical varicocele is associated with decreased left testicular size.
In addition, a discrepancy between the sizes of the two testes secondary to varicocele had also been demonstrated 13,14, suggesting that testicular size could be a prognostic factor for successful varicocele repair 15–17. Patel and Sigman 18 added that testicular size discrepancy is two times more common in infertile men with varicocele than in men without varicocele and that testicular size discrepancy with a smaller left testicle is more common than size discrepancy with a smaller right testicle, regardless of the side of varicocele.
This study aimed to assess the effect of associated varicocele on testicular size in infertile men.
Patients and methods
A total of 250 infertile men were investigated, recruited prospectively from the Andrology Department, University Hospital, after Institutional Review Board approval and informed consents. They were divided into three groups, matched in terms of age and semen parameters: men with left-sided varicocele (n=100), men with bilateral varicocele (n=100), and men without varicocele (n=50). Exclusion criteria were hypogonadism, subclinical varicocele, orchitis, undescended testis, and testicular atrophy.
All men were subjected to history taking, genital examination, and semen analysis 19. Scrotal color Doppler ultrasound was performed using a 7.5 MHz high-resolution linear array transducer (Sonoline Versa plus; Siemens Medical System, Erlangen, Germany) with pulsed and color Doppler capabilities. Testicular size was automatically calculated by the length×antero-posterior×transverse dimensions×0.52 (ml).
The data were analyzed and expressed as mean values±SD, using SPSS version 17 (SPSS Inc., Chicago, Illinois, USA). An unpaired t-test was used to compare variables between groups. P<0.05 was set as statistically significant.
Infertile men with bilateral varicocele demonstrated a significant decrease in left or right mean testicular sizes, total testicular size as well as testicular size difference compared with infertile men with left-sided varicocele or without varicocele. Infertile men with left-sided varicocele demonstrated a significant decrease in left or right mean testicular size and total testicular sizes compared with infertile men without varicocele. The mean testicular size demonstrated a significant increase in infertile men with left-sided varicocele compared with infertile men with bilateral varicocele or without varicocele (Table 1). Testicular size demonstrated a significant positive correlation with sperm concentration (r=0.532, P=0.001) and a nonsignificant correlation with sperm motility (r=0.049, P=0.472) as well as percentages of sperm abnormal forms (r=−0.035, P=0.317).
In the current study, infertile men with left-sided varicocele showed a significant decrease in ipsilateral testicular size compared with infertile men without varicocele. In addition, infertile men with bilateral varicocele showed a significant decrease in the size of both testicles compared with the other studied groups. Previously, Lipshultz and Corriere 20 had observed progressive testicular hypotrophy in patients with varicocele compared with healthy controls, where Sigman and Jarow 21 observed that 50% of infertile patients with unilateral varicocele have ipsilateral testicular hypotrophy. Zini et al. 12 were the first to show the negative influence of varicocele on the testicular size with ultrasound-derived measurements. Zini et al. 13 confirmed this, adding that the degree of unilateral testicular hypotrophy was proportionate to the clinical grade of varicocele as well as the maximum internal spermatic vein diameters.
There was a significant increase in the mean testicular size discrepancy in infertile men with unilateral compared with bilateral varicocele and those without varicocele. Pinto et al. 22 reported that the mean testicular size difference for fertile men without varicocele was significantly lower than in fertile men with varicocele or infertile men with varicocele. Sakamoto et al. 14 showed that fertile patients with left-sided varicocele had a larger percentage of testicular size differences than infertile patients or fertile patients without scrotal abnormalities. They also added that the relative decrease in left testicular size was not restricted to patients with varicocele as infertile patients had smaller mean left and/or right testicular sizes than fertile patients, irrespective of the presence of varicocele.
These relationships may actually have an impact on fertility. Sigman and Jarow 21 showed that infertile patients with testicular hypotrophy with unilateral varicocele have worse semen parameters than those without hypotrophy. Preston et al. 23 added that patients who show a testicular volume discrepancy that is steadily increasing should be considered for surgical intervention. Hence, the testicular trophic healing observed in 81.5% of the operated patients by Messina et al. 24 led to the belief that an early correction can allow a rapid volumetric increase and an improved function of the gonad. Sakamoto et al. 25 confirmed these findings, demonstrating that left-sided varicocele repair could lead to increased left testicular size concomitant with an improved semen profile.
Infertile men with varicocele have significant decreases in ipsilateral and total testicular size and significant increases in testicular size discrepancy. Future studies should compare these data with fertile men with/without varicocele to assess whether decreased testis size is because of varicocele impact or the infertility status.
Conflicts of interest
There are no conflicts of interest.
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