Varicocele impact on testicular size of infertile men in unilateral or bilateral associated cases
Taha, Emad A.a; Wahed, Saad R. Abdelb; Mostafa, Taymourc
aDepartment of Dermatology and Andrology, Faculty of Medicine, Assiut University
bDepartment of Radiology, Faculty of Medicine, Al-Azhar University, Assuit
cDepartment of Andrology & Sexology, Faculty of Medicine, Cairo University, Cairo, Egypt
Correspondence to Taymour Mostafa, MD, Department of Andrology & Sexology, Faculty of Medicine, Cairo University, Cairo 11562, Egypt Tel: +2 0105150297; e-mail: firstname.lastname@example.org
Received April 12, 2011
Accepted August 20, 2011
Aim: To assess varicocele impact on the testicular size of infertile men in unilateral-associated or bilateral-associated cases.
Patients and methods: A total of 250 infertile men were investigated subdivided into; men with left-sided varicocele (n=100), men with bilateral varicocele (n=100), and men without varicocele (n=50). They were subjected to history taking, clinical examination, scrotal color Doppler for testicular size, and semen analysis.
Main outcome measures: Testicular size(s) in relation to varicocele association.
Results: There was a significant decrease in the mean testicular size in infertile men with unilateral or bilateral varicocele compared with infertile men without varicocele. Testicular volume discrepancy was more evident in infertile men with left-sided varicocele compared with infertile men with bilateral varicocele or without varicocele.
Conclusion: Infertile men with varicocele have a significant decrease in ipsilateral as well as total testicular size and significant increased testicular size discrepancy.
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.
1. Mostafa T, Anis T, Imam H, El Nashar AR, Osman IA. Seminal reactive oxygen species-antioxidant relationship in fertile males with and without varicocele. Andrologia. 2009;41:125–129
2. Abdel Aziz MT, Mostafa T, Atta H, Kamal O, Kamel M, Hosni H, et al. Heme oxygenase enzyme activity in seminal plasma of oligoasthenoteratozoospermic males with varicocele. Andrologia. 2010;42:236–241
3. Takihara H, Sakatoku J, Cockett AT. The pathophysiology of varicocele in male infertility. Fertil Steril. 1991;55:861–868
4. Mostafa T, Anis TH, El Nashar A, Imam H, Othman IA. Varicocelectomy reduces reactive oxygen species levels and increases antioxidant activity of seminal plasma from infertile men with varicocele. Int J Androl. 2001;24:261–265
5. Mostafa T, Anis TH, Ghazi S, El Nashar AR, Imam H, Osman IA. Reactive oxygen species and antioxidants relationship in the internal spermatic vein blood of infertile men with varicocele. Asian J Androl. 2006;8:451–454
6. Hassan A, El Nashar EM, Mostafa T. Programmed cell death in varicocele-bearing testes. Andrologia. 2009;41:39–45
7. Shiraishi K, Takihara H, Matsuyama H. Elevated scrotal temperature, but not varicocele grade, reflects testicular oxidative stress-mediated apoptosis. World J Urol. 2010;28:359–364
8. Steckel J, Dicker AP, Goldstein M. Relationship between varicocele size and response to varicocelectomy. J Urol. 1993;149:769–771
9. Culha M, Mutlu N, Acar O, Baykal M. Comparison of testicular volumes before and after varicocelectomy. Urol Int. 1998;60:220–223
10. Pasqualotto FF, Lucon AM, de Goes PM, Sobreiro BP, Hallak J, Pasqualotto EB, et al. Semen profile, testicular volume and hormonal levels in infertile patients with varicoceles compared with fertile men with and without varicoceles. Fertil Steril. 2005;83:74–77
11. Ku JH, Son H, Kwak C, Lee SE, Lee NK, Park YH. Impact of varicocele on testicular volume in young men: significance of compensatory hypertrophy of contralateral testis. J Urol. 2002;168(4 Pt 1):1541–1544
12. Zini A, Buckspan M, Berardinucci D, Jarvi K. The influence of clinical and subclinical varicocele on testicular volume. Fertil Steril. 1997;68:671–674
13. Zini A, Buckspan M, Berardinucci D, Jarvi K. Loss of left testicular volume in men with clinical left varicocele: correlation with grade of varicocele. Arch Androl. 1998;41:37–41
14. Sakamoto H, Ogawa Y, Yoshida H. Relationship between testicular volume and varicocele in patients with infertility. Urology. 2008;71:104–109
15. Marks JL, McMahon R, Lipshultz LI. Predictive parameters of successful varicocele repair. J Urol. 1986;136:609–612
16. Zucchi A, Mearini L, Mearini E, Fioretti F, Bini V, Porena M. Varicocele and fertility: relationship between testicular volume and seminal parameters before and after treatment. J Androl. 2006;27:548–551
17. Spinelli C, Di Giacomo M, Lo Piccolo R, Martin A, Messineo A. The role of testicular volume in adolescents with varicocele: the better way and time of surgical treatment. J Urol. 2010;184(4 Suppl):1722–1726
18. Patel SR, Sigman M. Prevalence of testicular size discrepancy in infertile men with and without varicoceles. Urology. 2010;75:566–568
19. World Health Organisation (WHO). WHO laboratory manual for the examination of human semen and sperm-cervical mucus interaction. 19994th ed. Cambridge, UK: Cambridge University Press
20. Lipshultz LI, Corriere JN Jr. Progressive testicular atrophy in the varicocele patient. J Urol. 1977;117:175–176
21. Sigman M, Jarow JP. Ipsilateral testicular hypotrophy is associated with decreased sperm counts in infertile men with varicoceles. J Urol. 1997;158:605–607
22. Pinto KJ, Kroovand RL, Jarow JP. Varicocele related testicular atrophy and its predictive effect upon fertility. J Urol. 1994;152(2 Pt 2):788–790
23. Preston MA, Carnat T, Flood T, Gaboury I, Leonard MP. Conservative management of adolescent varicoceles: a retrospective review. Urology. 2008;72:77–80
24. Messina M, Zagordo L, Di Maggio G, Molinaro F, Abate V, Nardi N. Testicular hypotrophy in varicocele: pre and postoperative echographic follow-up in the pediatric age. Minerva Urol Nefrol. 2006;58:151–155
25. Sakamoto H, Saito K, Ogawa Y, Yoshida H. Effects of varicocele repair in adults on ultrasonographically determined testicular volume and on semen profile. Urology. 2008;71:485–489
color Doppler; male infertility; testicular size varicocele; testis
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