Microanatomy of the left and right spermatic cords at subinguinal microsurgical varicocelectomy: comparative study of primary and redo repairs.

OBJECTIVES: To examine and compare the left and right spermatic cord arterial and lymphatic anatomy identified at primary and redo microsurgical subinguinal varicocelectomy. METHODS: We reviewed the operative reports of 335 consecutive microsurgical varicocelectomies performed by a single surgeon: 325 primary repairs and 10 reoperations. We recorded number of testicular arteries (internal and external spermatic) and lymphatic channels preserved at subinguinal microsurgical varicocelectomy, and evaluated the relationship between the right and left vascular anatomy at bilateral varicocelectomy. RESULTS: A total of 235 left-sided and 90 bilateral primary repairs were performed. A mean (+/-standard deviation) number of 2.4+/-1.0 arteries and 4.6+/-1.5 lymphatics were identified during the left-sided repairs. For bilateral repairs, there were 2.4+/-0.9 arteries and 4.4+/-1.2 lymphatics on the left and 2.2+/-0.9 arteries and 4.2+/-1.3 lymphatics on the right with a significant correlation between the number of right and left internal spermatic arteries (r=0.42). For the cohort of secondary (redo) varicocelectomies, we identified 2.3+/-0.6 arteries and 4.8+/-1.6 lymphatic channels (not significantly different from the primary varicocelectomy cohorts). CONCLUSIONS: The number of arteries and lymphatics preserved at microsurgical varicocelectomy is highly variable, but there is some similarity in the microanatomy of the right and left spermatic cords at the level of the external inguinal ring. The data also suggest that the number of arteries and lymphatic channels identified at a redo varicocelectomy is comparable to that observed during a primary varicocelectomy.

Identification of spermatozoa in archived testicular cancer specimens: implications for bench side sperm retrieval at orchiectomy.

OBJECTIVES: To evaluate the patterns of spermatogenesis in the normal testicular parenchyma of primary testicular cancers and estimate the feasibility of sperm retrieval at the time of radical orchiectomy. METHODS: We reviewed the archived histologic sections of 39 consecutive patients who had undergone radical orchiectomy for primary testicular cancer at 3 university-affiliated hospitals. We examined all areas of normal (noncancerous) testicular parenchyma to evaluate the level of spermatogenesis and presence of mature spermatozoa in these sections. A minimum of 100 seminiferous tubules were scored per case. We also evaluated the epididymal tubules for the presence of mature spermatozoa. A review of the clinical chart was performed to evaluate the relationship between clinical data and histologic findings. RESULTS: In nearly 40% of the cases evaluated (15/38), the predominant histologic pattern was full spermatogenesis. Mature spermatozoa were identified in nearly 80% (30/38) of the testicular histologic sections and in 50% (14/28) of the evaluable epididymal sections. Clinical stage (presence of extranodal disease) and tumor marker levels were related to the probability of identifying mature spermatozoa in the testis. CONCLUSIONS: The data suggest that sperm retrieval at the time of radical orchiectomy is a feasible fertility option, with a 40% probability of recovering spermatozoa by random biopsy of the noncancerous testicular parenchyma and an 80% probability of recovering spermatozoa with a more extensive dissection. In 50% men, spermatozoa may be recovered by epididymal aspiration alone.

Microsurgical varicocelectomy for infertile men with oligospermia: differential effect of bilateral and unilateral varicocele on pregnancy outcomes.

OBJECTIVES: To evaluate the pregnancy outcomes of two groups of oligospermic men with varicocele, one having a varicocelectomy (group 1) and the other electing not to have surgery (group 2), as varicocele represents the most common factor associated with male infertility and most reports indicate that varicocelectomy has a beneficial effect on male fertility and pregnancy outcome. PATIENTS AND METHODS: We retrospectively reviewed consecutive oligospermic men who had microsurgical varicocelectomy (233, group 1) between September 1996 and January 2002 and a consecutive group of oligospermic men with varicoceles who elected not to have surgery (127, group 2). The outcome measures included changes in semen variables, partner pregnancy rates (assisted and unassisted) and use of assisted reproductive technologies (ART). RESULTS: The mean sperm concentration and motility increased significantly after varicocelectomy (P < 0.05). The natural pregnancy rate in group 1 (38%) was higher than in group 2 (30%). The use of ART was significantly greater in group 2 than group 1. In the subset of couples with bilateral varicocele, the natural pregnancy rate was significantly higher in group 1 than group 2 (48% vs 15%, respectively, P = 0.008). CONCLUSIONS: This study suggests that the natural pregnancy rate is higher after varicocelectomy than in those not having surgery, although the difference was not statistically significant. However, in the subset of couples with bilateral varicocele, the spontaneous pregnancy rates were significantly higher after surgery.

Varicocele: red flag or red herring?

The debate concerning the relationship between varicocele and male infertility has been ongoing for several decades, and correction of varicocele for the treatment of male infertility remains controversial. Proponents of varicocele repair believe that there is an association between the two conditions and point to the many studies showing improvements in semen parameters and other markers of fertility after surgery as evidence of such a relationship. Opponents argue that the mere presence of dilated testicular veins does not necessarily imply that these lesions are the cause of a man's subfertility and that incontrovertible pregnancy outcome data after varicocele repair remains to be shown. To shed some light on this topic, we have reviewed the most current data concerning the impact of varicocele on male fertility and have analyzed the literature on the value of varicocele repair in the setting of male infertility. We have determined that whereas there is a definite association between varicocele and male infertility, a cause and effect relationship between varicocele and infertility has not been established conclusively. A critical review of the available pregnancy outcome data does support varicocelectomy as a viable option for infertile couples with a clinical varicocele.

Sperm head morphology is related to high deoxyribonucleic acid stainability assessed by sperm chromatin structure assay.

OBJECTIVE: To examine the relationship between sperm strict morphology and sperm chromatin integrity. DESIGN: Prospective study. SETTING: Infertility clinic. PATIENT(S): Eighty-seven consecutive semen samples from non-azoospermic men presenting for infertility evaluation and 6 samples from fertile donors. INTERVENTION(S): Assessment of standard semen parameters and sperm chromatin structure assay (SCSA) parameters (%DFI [DNA fragmentation index] and %HDS [high DNA stainability]). Evaluation of %HDS and %DFI after treatment with dithiothreitol (a thiol-reducing agent used to decondense sperm nuclei) was also undertaken. MAIN OUTCOME MEASURE(S): Relationship between sperm strict morphology defects and SCSA parameters (%DFI and %HDS). RESULT(S): We observed significant relationships between the percentage of normal sperm forms and both %HDS (r = -0.40) and sperm motility (r = 0.32). We also found significant relationships between sperm head defects and both %HDS (r = 0.40) and sperm concentration (r = -0.39). Sperm tail, midpiece, and neck defects were not significantly related to the SCSA parameters. Treatment of spermatozoa with dithiothreitol (to induce decondensation) resulted in a substantial increase in %HDS but no measurable change in %DFI. CONCLUSION(S): The observed relationship between sperm head defects and %HDS suggests that sperm head abnormalities may, in part, be due to incomplete sperm chromatin condensation.

Sperm DNA damage is associated with an increased risk of pregnancy loss after IVF and ICSI: systematic review and meta-analysis.

BACKGROUND: Sperm DNA damage is common amongst infertile men and may adversely impact natural reproduction, IUI-assisted reproduction and to a lesser degree IVF pregnancy. The aim of this study was to examine the influence of sperm DNA damage on the risk of spontaneous pregnancy loss after IVF and ICSI. METHODS: We conducted a systematic review and meta-analysis of studies on sperm DNA damage and pregnancy loss after an IVF and/or ICSI pregnancy. RESULTS: Two by two tables were constructed and odds ratios (ORs) were derived from 11 estimates of pregnancy loss (five IVF and six ICSI studies from seven reports). These 11 studies involved 1549 cycles of treatment (808 IVF and 741 ICSI cycles) with 640 pregnancies (345 IVF and 295 ICSI) and 122 pregnancy losses. The combined OR of 2.48 (95% CI 1.52, 4.04, P < 0.0001) indicates that sperm DNA damage is predictive of pregnancy loss after IVF and ICSI. CONCLUSIONS: In conclusion, sperm DNA damage is associated with a significantly increased risk of pregnancy loss after IVF and ICSI. These data provide a clinical indication for the evaluation of sperm DNA damage prior to IVF or ICSI and a rationale for further investigating the association between sperm DNA damage and pregnancy loss.

Microsurgical varicocelectomy for isolated asthenospermia.

PURPOSE: Varicocele represents the most common cause of male infertility, and most reports indicate that varicocelectomy has a beneficial effect on male fertility and pregnancy outcome. We evaluated the clinical outcomes of infertile couples with varicocele and isolated asthenospermia who chose to undergo varicocelectomy as well as those who chose not to undergo the procedure. MATERIALS AND METHODS: We performed a retrospective review of 118 consecutive infertile couples in whom the man presented with clinical varicocele and isolated asthenospermia (less than 50% motile sperm). All couples were presented with possible treatment options (observation, varicocelectomy, assisted reproductive technologies). The clinical characteristics and outcomes of 2 subgroups of men--those who elected to undergo surgery (varicocelectomy, 69) and those who did not (49)--were examined and compared. RESULTS: Mean male and female patient age, duration of infertility and baseline total motile sperm count were not significantly different in the control and surgery groups. The mean total motile sperm count increased significantly after varicocelectomy (29.6 million preoperatively vs 39.0 million postoperatively, p <0.05). The spontaneous pregnancy rate was significantly higher in the surgery group compared to the control group (65% vs 32%, respectively, p <0.01). The combined spontaneous and intrauterine insemination pregnancy rate was also significantly higher in the surgery group compared to the control group (74% vs 36%, respectively, p <0.01). Use of in vitro fertilization/intracytoplasmic sperm injection was significantly higher in the control group compared to the surgery group (32% vs 11%, respectively, p <0.05). CONCLUSIONS: Our data support the practice of varicocelectomy for the treatment of clinical varicocele and isolated asthenospermia.

Varicocelectomy for infertile couples with advanced paternal age.

OBJECTIVES: To evaluate the reproductive outcomes of infertile couples with a clinical varicocele and advanced paternal age. METHODS: We reviewed the clinical records of 581 consecutive, non-azoospermic men presenting with a clinical varicocele and infertility. RESULTS: We identified 115 men aged 40 years and older and 466 men younger than 40 years with a clinical varicocele and infertility. The proportion of men with secondary infertility was significantly higher in the group of men aged 40 years and older compared with the men younger than 40 years (43% [50 of 115] versus 19% [87 of 466], respectively; P <0.001). There were no significant differences in baseline sperm parameters and in spontaneous pregnancy rates after varicocelectomy in couples with advanced paternal age (40 years or older) compared with the younger couples (49% versus 39%, respectively). However, the spontaneous pregnancy rate in couples with advanced paternal age (40 years or older) who underwent varicocelectomy was significantly greater than that of the age-matched control group who did not undergo surgery (49% versus 21%, respectively; P <0.05). CONCLUSIONS: The results of this study suggest that paternal age does not adversely influence pregnancy outcome after varicocelectomy. The data support the practice of varicocelectomy for treatment of clinical varicocele and infertility in older men.

Natural history of varicocele management in the era of intracytoplasmic sperm injection.

OBJECTIVE: To evaluate the outcomes of infertile couples with varicocele. DESIGN: Retrospective study. SETTING: University infertility clinic. PATIENT(S): Six hundred ten consecutive infertile couples in whom the man was found to have a clinical varicocele. INTERVENTION(S): Microsurgical varicocelectomy and assisted reproductive technologies (ARTs; intrauterine insemination and intracytoplasmic sperm injection). MAIN OUTCOME MEASURE(S): Clinical characteristics, pregnancy rates, and ART utilization in two subgroups of couples (those who elected to undergo varicocelectomy and those who did not). RESULT(S): Sixty percent of the couples (363/610) opted for varicocele repair. The surgical and nonsurgical groups had comparable ages and duration of infertility. However, sperm concentration and motility were significantly lower in the surgical group, compared with in the observation one. As well, the surgical group had a significantly higher prevalence of primary infertility (80% vs. 71%) and had significantly smaller testicles bilaterally. Utilization of ART was significantly higher in the observation group compared with the surgical group (54% vs. 38%). Overall pregnancy rates (spontaneous + assisted pregnancies) in the observation and surgical group were not significantly different. CONCLUSION(S): This study suggests that men with poorer baseline characteristics are more likely to opt for varicocele repair. Furthermore, couples electing not to repair the varicocele are more likely to undergo ART procedures to improve their chances of conception.

Severe soft tissue infection of the thigh after vaginal erosion of transobturator tape for stress urinary incontinence.

Since the beginning of use of synthetic midurethral slings, several complications, usually benign, have been reported. Recently, three consecutive cases of severe thigh infection secondary to transobturator insertion of a synthetic tape alarmed us. This is a case report about these three cases and a review of literature about complications of transobturator tapes.

Readmission for small-bowel obstruction in the early postoperative period: etiology and outcome.

OBJECTIVES: To determine the frequency of readmission for early postoperative small-bowel obstruction (SBO), to highlight factors that may predispose to this condition, to define the risks of strangulation and to compare the immediate and long-term risks and benefits of operative versus nonoperative treatment. DESIGN: A chart review. SETTING: The Sir Mortimer B. Davis-Jewish General Hospital, a university-affiliated teaching hospital in Montreal. PATIENTS: Out of a total of 1001 cases of SBO in 552 patients, 30 patients were readmitted within 50 days of a previous laparotomy with the diagnosis of SBO. INTERVENTION: Selective nonoperative management and exploratory laparotomy. MAIN OUTCOME MEASURES: The value of nonoperative management and need for operation. RESULTS: Adhesions were the cause of the obstruction in most cases (24); other causes were Crohn's disease (2), hernia (1), malignant neoplasm (1) and a combination of adhesions and malignant disease (2). Thirteen (43%) of the procedures preceding the obstruction were primary small-bowel operations. There was only 1 episode of strangulated bowel. Of the patients readmitted for SBO, 7 (23%) were treated operatively with a long-term recurrence rate of 57% compared with 63% for those treated nonoperatively for the SBO. The median time to recurrence was 0.1 years (range from 0.02-6 yr) for those whose SBO was managed operatively, compared with 0.7 years (range from 0.08-5 yr) for those managed nonoperatively for the SBO. The median length of stay for patients managed operatively for SBO was 12 days (range from 9-17 d) compared with 6 days (range from 2-33 d) for those managed nonoperatively. CONCLUSIONS: Readmission for SBO within 50 days of a previous laparotomy represents a small percentage of all cases of SBO. They frequently follow small-bowel operations. Cases of strangulation are no more common than in general cases of SBO. Patients treated nonoperatively for SBO did not experience less favourable outcomes with respect to resolution of symptoms, length of stay, risk of recurrence and reoperation. Thus, operative intervention is not necessary in an otherwise stable patient.