Optimal use of infertility diagnostic tests and treatments. The ESHRE Capri Workshop Group. Diagnostic accuracy of sperm DNA degradation index (DDSi) as a potential noninvasive biomarker to identify men with varicocele-associated infertility Sperm chromatin condensation in infertile men with varicocele before and after surgical repair. Effects of varicocele on serum testosterone and changes of testosterone after varicocelectomy: a prospective controlled study. Controlled trial of high spermatic vein ligation for varicocele in infertile men. The effect of adjuvant vitamin C after varicocele surgery on sperm quality and quantity in infertile men: a double blind placebo controlled clinical trial Varicocelectomy for male infertility: a comparative study of open, laparoscopic and microsurgical approaches. Treatment of varicocele: randomized prospective study on open surgery versus Tauber antegrade sclerotherapy. Microsurgical and nonmagnified subinguinal varicocelectomy for infertile men: a comparative study. Sperm protamine mRNA ratio and DNA fragmentation index represent reliable clinical biomarkers for men with varicocele after microsurgical varicocele ligation. Subinguinal microvaricocelectomy versus retroperitoneal varicocelectomy: comparative study of complications and surgical outcome. Update on treatment of varicocele: counselling as effective as occlusion of the vena spermatica. Decreased sperm DNA fragmentation after surgical varicocelectomy is associated with increased pregnancy rate. Single incision transumbilical laparoscopic varicocelectomy versus the conventional laparoscopic technique: A randomized clinical study. Effect of microsurgical varicocelectomy on human sperm chromatin and DNA integrity: a prospective trial. Pregnancy outcomes after assisted reproductive technology. Pentoxifylline and antioxidants improve sperm quality in male patients with varicocele. Effect of folic acid and zinc sulphate on endocrine parameters and seminal antioxidant level after varicocelectomy Reporting of Sex Effects by Systematic Reviews on Interventions for Depression, Diabetes, and Chronic Pain Adolescent varicocele repair: long-term results and comparison of surgical techniques according to optical magnification use in 100 cases at a single university hospital. The natural history of semen parameters in untreated asymptomatic adolescent varicocele patients: A retrospective cohort study. Placebo-controlled, double-blind, cross-over trial of glutathione therapy in male infertility. Increased numbers of DNA-damaged spermatozoa in samples presenting an elevated rate of numerical chromosome abnormalities.
The general definition of infertility is a lesser capacity to conceive than the mean capacity of the general population and infertile couples can be characterized in two groups : those unable to conceive without therapy and those who are hypofertile , but conceive without therapy . The initial diagnostic tests for infertility should include a midluteal phase progesterone assay , a semen analysis and a test for tubal patency such as a hysterosalpingogram . Measuring progesterone is the best test for confirming ovulation . To predict ovulation , evaluating the luteinizing hormone ( LH ) surge is the best single assay while measurement of LH plus preovulatory oestrogen is the best prediction . Today primary investigation of the morphology of the uterus and tubes should be by hysterosalpingography . However , ultrasound , particularly with simple contrast media , is likely to gain in importance . Laparoscopy should be reserved as a further diagnostic procedure or in combination with endoscopic surgery . There are situations in which semen analysis is of utmost importance and of absolute predictive value , namely , in cases of azoospermia . In general semen analysis remains a substantial part of the fertility workup , but any consideration of its predictive value has to be cautious . Performing genetic tests before , during and after assisted reproductive techniques ( ART ) is an intrinsic part of good clinical practice . These tests allow one to reach a correct diagnosis , to give adequate genetic counselling to the couple and their families in cases such as ( i ) women with Turner syndrome ; ( ii ) men with 47 , XXY ; ( iii ) men or women with structural chromosomal aberration ; ( iv ) men with Yq11 deletion or ( v ) men with congenital bilateral absence of vas deferens . Patients should , of course , be made aware of the occurrence of de-novo mutations taking place in the testis and in the embryo . Treatment of some causes of infertility are of proven value . For example induction of ovulation . Others are more controversial . Among the many empirical treatments suggested for the treatment of the various form of subfertility , surgical treatment of varicocele in the male , treatment of pelvic endometriosis in the female and the efficacy of the ART strategies offered to the subfertile couple are considered . Many varicocele studies are of poor quality . A few are good , but small in size . They do not show an improvement in pregnancy rates . Therefore , at the moment , there is insufficient scientific evidence for recommending routinely surgical treatment in subfertile and /or oligozoospermic men with a varicocele . R and omized , double-blind controlled trials demonstrated the modest efficacy of endometriosis ablation in increasing the pregnancy rate in infertile women while drugs suppressing ovulation are of no benefit to infertile women with endometriosis . Although the largest body of evidence available suggests that IVF success declines in repeated ART cycles , an accurate estimate of the true success rate in the ' nth ' cycle of IVF treatment is not possible . Similarly little is still known of the reasons for the overall low continuation rates with IVF treatment Abstract Purpose Varicocele is a frequent cause of impaired testicular function that has been associated with increased levels of sperm DNA fragmentation ( SDF ) . Sperm with de grade d DNA ( DDS ) , as observed using the sperm chromatin dispersion ( SCD ) test , represent a sub population of spermatozoa with extensive DNA and nuclear protein damage . The aim of this work was to determine the usefulness of sperm DNA degradation index ( DDSi ) as a novel noninvasive biomarker to identify infertile men with varicocele . Methods A total of 593 semen sample s obtained from men attending infertility clinics were analyzed for SDF and DDS with the SCD test . These sample s were classified as : ( 1 ) fertile donors ; ( 2 ) infertile patients with least two failed assisted reproduction cycles ; ( 3 ) leukocytospermia ; ( 4 ) Chlamydia trachomatis infection ; ( 5 ) testicular cancer , and ( 6 ) infertile men with varicocele . The DDSi was obtained by determining the proportion of DDS in the whole sperm population presenting with fragmented DNA . The diagnostic accuracy of DDSi was evaluated by correlation coefficient and receiver operating characteristics analyses . Results A positive correlation ( r ≥ 0.52 ) was observed between the SDF and the frequency of de grade d sperm in all patient groups . The sperm DNA degradation index ( DDSi ) was at least twice as higher in infertile men with varicocele ( mean : 0.54 ) compared with other clinical conditions and fertile donors ( means ranging from 0.02 to 0.21 ; P < 0.0001 ) . A DDSi ≥ 0.33 identified patients with varicocele with 94 % accuracy . Conclusion Although DDS is not pathognomonic of varicocele , the DDSi is a useful noninvasive biomaker to identify infertile individuals with varicocele when examining sperm DNA damage during a routine semen analysis . This finding may alert practitioners and laboratories performing semen analysis that in the presence of an abnormal DDSi it is likely that a given patient has varicocele . It is therefore strongly recommended that such patients be referred to urologists in order to undergo a full and rological examination and be properly counseled OBJECTIVE To assess sperm chromatin integrity in infertile men with varicocele before and after surgical repair . DESIGN Prospect i ve . SETTING Academic setting . PATIENT(S ) Seventy-two infertile men with varicocele compared with 20 healthy fertile men . INTERVENTION(S ) History taking , genital examination , semen analysis , sperm chromatin condensation assessment by aniline blue stain before and 3 months after varicocelectomy . MAIN OUTCOME MEASURE(S ) Stained sperm heads ( abnormal chromatin condensation ) before and 3 months after varicocelectomy . RESULT ( S ) The mean percentage of aniline blue-stained sperm heads was significantly higher in infertile men with varicocele compared with fertile controls . The mean percentage of stained sperm heads was significantly decreased in infertile men with varicocele 3 months after surgery compared with the preoperative data . There was a significant negative correlation between percentage of stained sperm heads and normal morphology where nonsignificant correlation was elicited regarding sperm count and sperm motility . CONCLUSION ( S ) There is a significant increase of abnormal sperm chromatin condensation in infertile men with varicocele that is markedly improved after varicocelectomy OBJECTIVE To examine the hypotheses that clinical varicoceles affect baseline serum total testosterone levels ( T ) and varicocelectomy improves T. MATERIAL S AND METHODS This prospect i ve , nonr and omized , controlled study involved 4 groups of adult men . Varicocele-infertile treatment group ( VIT ) included 66 men who underwent varicocelectomy . Thirty-three varicocele-infertile control men ( VIC ) and 33 varicocele-fertile control men ( VFC ) were only observed . Normal-control ( NC ) group included 33 fertile men without varicocele . Varicocele groups were stratified into baseline hypogonadal ( T < 300 ng/dL ) or eugonadal ( T ≥300 ng/dL ) subgroups . Main outcome measurements were between-group baseline T differences ; and within-group T changes at 6- and 12-month follow-ups of men with varicocele . P < .05 was considered significant . RESULTS Means ( st and ard deviations ) of baseline T in VIT , VIC , VFC , and NC were 347.4 ( 132.1 ) , 339.7 ( 125.8 ) , 396.6 ( 164.9 ) , and 504.8 ( 149.7 ) ng/dL , respectively . The baseline T levels of varicocele groups were comparable , whereas they were significantly low compared with NC group . At 6-month follow-up , VIT demonstrated significant T improvements ( mean change = 44.7 ng/dL ; 12.9 % ; P < .0001 ) . T changes were more remarkable among baseline hypogonadals ( mean change = 93.7 ng/dL ; 40.1 % ; P < .0001 ) compared with eugonadals ( mean change = 8.6 ng/dL ; 2.01 % ; P = .1223 ) . These improvements were persistent at 12-month follow-up . Contrariwise , VIC and VFC exhibited nonsignificant T changes . Postvaricocelectomy T changes correlated significantly and inversely with baseline T ( r = -0.689 ; P < .0001 ) . This correlation was stronger and more significant among hypogonadals ( r = -0.528 ; P = .004 ) than eugonadals ( r = -0.400 ; P = .013 ) . T improvements also exhibited significant positive correlations with preoperative and postoperative sperm concentrations . CONCLUSION Baseline T was significantly low in men with varicocele compared with normal men . Varicocelectomy yielded significant T improvements among hypogonadal men but insignificant changes in eugonadals . T changes correlated strongly and significantly with baseline T and sperm concentrations OBJECTIVE To determine whether high ligation is an effective treatment for infertile men with clinical varicocele . DESIGN A r and omized , controlled trial of high spermatic vein ligation was carried out . The patients were treated and observed for 3 years . SETTING Infertility treatment clinic and and rology laboratory in a hospital . PATIENTS Infertile men with abnormal semen analysis because of varicocele only . INTERVENTION High ligation 1 year postrecruitment ( group A ) and at the beginning of the study ( group B ) . RESULTS Among the 20 couples in group A , 2 pregnancies ( 10 % ) were achieved within the 1st year of observation period . During the year after high ligation , there were 8 pregnancies ( 44.4 % ) , and during the 2nd year after high ligation , there were 4 more pregnancies ( 22.2 % ) . In group B , 15 pregnancies ( 60 % ) occurred within the 1st year after operation . Three pregnancies ( 12 % ) and 1 pregnancy ( 4 % ) occurred during the 2nd and 3rd year , respectively . After operation in all patients of both groups , there was significant improvement in semen parameters , regardless of pregnancy occurrence . The difference in pregnancy rate ( PR ) between the operated group B and nonoperated group A during the 1st year of study was found to be highly significant . CONCLUSIONS It is concluded that in a population of infertile men presenting varicocele as the only demonstrable factor of infertility , the varicocele is clearly associated with infertility and reduced testicular function , and its correction by ligation improves sperm parameters and fertility rate . Furthermore , the highest PR in both groups occurred during the 1st year postoperation Varicocele is one of the most common causes of male infertility and spontaneous pregnancy rate after varicocelectomy is only about 30 % . The most important seminal antioxidant is vitamin C but recent studies about the effects of vitamin C on spermatogenesis are controversial ; therefore , we decided to evaluate its role after varicocelectomy . In a double blind r and omized controlled clinical trial , 115 men with infertility and clinical varicocele with abnormal semen analyses were recruited . After surgery , the intervention group received vitamin C ( 250 mg bid ) and the control group received placebo for three months  . Mean sperm count , motility , and morphology index of two semen analyses ( before and after surgery ) were compared between the two groups . Univariate general linear model and stepwise linear regression were used in analysis . The mean age ( ±SD ) of participants was 27.6±5.3 years . Vitamin C group had statistically significant better normal motility ( 20.8 vs. 12.6 , P=0.041 ) and morphology ( 23.2 vs. 10.5 , P<0.001 ) than placebo group . Considering the values prior to surgery as covariate , vitamin C was not effective on sperm count ( P=0.091 ) ; but it improved sperm motility ( P=0.016 ) and morphology ( P<0.001 ) even after excluding the confounding effect of age ( P=0.044 and P=0.001 , respectively ) . Vitamin C was also an independent factor in predicting motility and normal morphology after surgery . Ascorbic acid can play a role as adjuvant treatment after varicocelectomy in infertile men PURPOSE We compared the outcomes of 3 techniques of varicocelectomy in infertile patients with varicocele . MATERIAL S AND METHODS The study included 298 infertile patients ( 446 varicoceles ) who were r and omized to varicocelectomy by an open inguinal technique in 92 , laparoscopy in 94 and subinguinal microsurgery in 112 . The 3 techniques were compared regarding intraoperative , and early and late postoperative parameters , changes in semen parameters and the pregnancy rate . Patients were followed a + /- mean + /- SD of 21 + /- 9 months ( range 4 to 35 ) . RESULTS Operative time was significantly longer in the microscopic group . Early postoperative complications were comparable in the 3 groups . At followup none of the patients in the microsurgical group had hydrocele , while it was observed in 4 of 143 ( 2.8 % ) in the open group and in 8 of 148 ( 5.4 % ) in the laparoscopy group , representing a significance difference in favor of microsurgery . The incidence of recurrent varicocele was significantly lower in the microsurgical group than in the open and laparoscopy groups ( 4 of 155 patients or 2.6 % vs 16 of 143 or 11 % and 25 of 148 or 17 % , respectively ) . Compared to preoperative values in the 3 groups postoperative semen parameters showed significant improvement in sperm concentration , motility and morphology . The incidence of patients with improved sperm count and motility was significantly higher in the microsurgical group . The pregnancy rate at 1 year was not significantly different among the 3 groups . CONCLUSIONS Compared with open and laparoscopic varicocele treatment microsurgical varicocelectomy has the advantages of no hydrocele formation , a lower incidence of recurrent varicocele , and better improvement in sperm count and motility The goal of this r and omized prospect i ve study in patients with varicocele was to evaluate the outcome following open surgery with inguinal approach versus ante grade sclerotherapy according to the Tauber procedure . From January 2002 to November 2003 , we recruited 64 patients with left varicocele for this study . All patients were clinical ly examined , before surgery and again 8 months postsurgery , by objective examination , scrotal color Doppler ultrasound , and semen analysis . These patients were r and omized in a balanced 4-block pattern : depending on r and omization , the patients underwent open surgery ( group A : 32 patients ) or ante grade sclerotherapy according to the Tauber procedure ( group B : 32 patients ) . At the current follow-up , it is possible to evaluate all the patients for whom we have preoperative and postoperative Doppler imaging and semen analysis . An analysis of seminal parameters shows a statistically significant improvement of the rate of fast progressive spermatozoa ( P < .05 ) and reduction in immotile spermatozoa ( P < .01 ) in those patients who underwent sclerotherapy compared to the patients who underwent open surgery . The outcomes of all other parameters ( number and morphology ) are fully comparable . Operating time is decidedly shorter for ante grade sclerotherapy ( P < .01 ) , but there are no significant differences in terms of early or late postoperative complications . It is widely known that varicocele is a condition found in 9 % to 23 % of the male population around the world ; this percentage rises to 40 % among infertile males . The treatment of this condition not only resolves clinical symptoms but also stops continuous damage to spermatogenesis , thereby potentially improving fertility . Our experience demonstrates that sclerotherapy ( Tauber procedure ) combines shorter surgical time and faster recovery of normal daily activities with significant improvement in sperm motility OBJECTIVE To compare semen parameters , pregnancy , recurrence , and complication rates after microsurgical and nonmagnified subinguinal varicocelectomy for infertile men . DESIGN Prospect i ve , r and omized study . SETTING Ghodran General Hospital , Kingdom of Saudi Arabia . PATIENT(S ) One hundred sixty-two infertile male patients with varicocele . INTERVENTION(S ) Eighty-two patients were treated by microsurgical subinguinal varicocelectomy ( MSSIV ) ( group I ) , whereas 80 patients were treated by conventional , nonmagnified subinguinal varicocelectomy ( NMSIV ) ( group II ) . MAIN OUTCOME MEASURE(S ) The patients were postoperatively evaluated by physical examination and semen analysis after 4 and 12 months . Pregnancy rate was monitored during the follow-up period . RESULT ( S ) Postoperatively , mean sperm count and motility improved significantly in both groups : 42.7 % and 67.1 % of the MSSIV group and 23.7 % and 33.8 % of the NMSIV group showed ≥50 % improvement in sperm count and motility after 1 year . Patients having bilateral varicocele showed significantly better improvement of sperm count than those with unilateral varicocele after both MSSIV and NMSIV . The pregnancy rate at the end of the follow-up period reached 37.8 % in the MSSIV group and 21.2 % in the NMSIV group . The recurrence rate was zero in the MSSIV group and 11.3 % in the NMSIV group . The rate of hydrocele formation was 1.2 % in the MSSIV group and 8.7 % in the NMSIV group . CONCLUSION ( S ) Microsurgical subinguinal varicocelectomy has a better improving effect on sperm count and motility , higher spontaneous pregnancy rates , and lower postoperative recurrence and hydrocele formation than conventional subinguinal varicocelectomy in infertile men PURPOSE We investigated whether the sperm protamine-1/2 mRNA ratio and DNA fragmentation index are reliable biomarkers in patients with clinical varicocele . MATERIAL S AND METHODS We performed a prospect i ve study in 42 subfertile patients with left clinical varicocele and 10 normozoospermic healthy donors with proven fertility . All patients and female partners were seen 3 and 6 months after varicocelectomy for fertility examination .  Real-time quantitative reverse transcriptase-polymerase chain reaction and SCSA ® were performed to analyze the sperm protamine-1/2 mRNA ratio and DNA fragmentation index . RESULTS The protamine-1/2 mRNA ratio and DNA fragmentation index were significantly higher in the preoperative group than in the control group ( p < 0.01 ) . After varicocelectomy in the pregnant group the protamine-1/2 mRNA ratio recovered to the normal value and the DNA fragmentation index was significantly lower than in the preoperative group ( p < 0.01 ) . In the nonpregnant group the protamine-1/2 mRNA ratio and DNA fragmentation index did not differ ( p > 0.05 ) . However , significant differences were present preoperatively according to varicocele severity in the protamine-1/2 mRNA ratio and DNA fragmentation index ( p < 0.05 and < 0.01 , respectively ) with the highest values in the grade 3 group . Nevertheless , postoperatively no difference in varicocele severity was noted ( p > 0.05 ) . The protamine-1/2 mRNA ratio was strongly related to preoperative and postoperative sperm concentration ( Rs -0.238 , p < 0.01 ) , progressive motility ( Rs -0.327 , p < 0.01 ) , total motility ( Rs -0.206 , p < 0.05 ) and DNA fragmentation index ( Rs 0.293 , p < 0.01 ) except for normal morphology ( Rs -0.064 , p > 0.05 ) . CONCLUSIONS The sperm protamine-1/2 mRNA ratio and DNA fragmentation index can effectively be used to evaluate male fertility . Male infertility due to varicocele may be associated with protamine deficiency and sperm DNA damage . The post-varicocelectomy protamine-1/2 mRNA ratio and DNA fragmentation index are associated with the post-varicocelectomy pregnancy rate OBJECTIVES To compare and assess objective ly the postoperative outcome parameters of both microsurgical subinguinal artery sparing and retroperitoneal high ligation techniques for varicocele in infertile men . METHODS We performed a prospect i ve study that included 413 consecutive patients who presented with varicocele . Of the 413 patients , 304 underwent subinguinal varicocelectomy ( group 1 ) and 109 patients underwent high ligation varicocelectomy ( group 2 ) .  Subinguinal varicocelectomies were performed under local anesthesia , with intravenous propofol sedation administered as needed . The operating microscope ( x10 to x16 ) was used to spare the arteries and lymphatics . High ligation was performed through a retroperitoneal approach . RESULTS All patients went home on the evening after surgery with minimal discomfort . No intraoperative complications occurred . The internal spermatic artery was identified in all microvaricocelectomy cases . No testicular atrophy occurred in either group . Five ( 1.6 % ) and seven ( 6.4 % ) hydroceles were identified at the 3-month postoperative visit in groups 1 and 2 , respectively . CONCLUSIONS Microvaricocelectomy is safe and effective and associated with a rapid recovery and minimal morbidity . However , it requires microsurgical training This prospect i ve r and omized study was performed in order to investigate the effects of interventive treatment or counselling on pregnancy rates in infertile couples in whose male partners a varicocele was diagnosed . The present report extends a previous study using the same design . A total of 125 couples were included in the current study while the previous report comprised 95 couples . Couples fulfilling the inclusion criteria were allocated r and omly either to interventive treatment ( surgical ligation or angiographic embolization of the spermatic vein ) ( n = 62 ) or to counselling as the sole treatment ( n = 63 ) . Couples were followed over the subsequent 12 months and seen at 3-monthly intervals . At the end of the 12 month period pregnancy rates , as the main outcome measure , were 29 % in the group given interventive treatment and 25.4 % in the counselled group and were not significantly different . The only significant difference found , regardless of treatment modality , was the wives ' age at admittance  :  the 34 wives achieving a pregnancy were 28.8 + /- 0.6 years ( mean + /- SE ) old while the 91 non-pregnant wives were 31.2 + /- 0.3 years old ( P < 0.05 ) . The study suggests that regular counselling of the infertile couples is as effective as interventive treatment of varicoceles in achieving pregnancies PURPOSE We prospect ively evaluated changes in sperm chromatin structure in infertile patients before and after surgical repair of varicocele , and the impact on the pregnancy rate . MATERIAL S AND METHODS Included in the study were 49 men with at least a 1-year history of infertility , a palpable varicocele and oligospermia . World Health Organization semen analysis and sperm DNA damage expressed as the DNA fragmentation index using the sperm chromatin structure assay were assessed preoperatively and postoperatively . Pregnancy ( spontaneous and after assisted reproductive technique ) was recorded 2 years after surgery . RESULTS Mean sperm count , sperm concentration and sperm progressive motility improved significantly after varicocelectomy from 18.3 × 10(6 ) to 44.4 × 10(6 ) , 4.8 × 10(6)/ml to 14.3 × 10(6)/ml and 16.7 % to 26.6 % , respectively ( p < 0.001 ) . The DNA fragmentation index decreased significantly after surgery from 35.2 % to 30.2 % ( p = 0.019 ) . When the definition of greater than 50 % improvement in sperm concentration after varicocelectomy was applied , 31 of 49 patients ( 63 % ) responded to varicocelectomy . After varicocelectomy 37 % of the couples conceived spontaneously and 24 % achieved pregnancy with assisted reproductive technique . The mean postoperative DNA fragmentation index was significantly higher in couples who did not conceive spontaneously or with assisted reproductive technique ( p = 0.033 ) . CONCLUSIONS After varicocelectomy sperm parameters significantly improved and sperm DNA fragmentation was significantly decreased . Low DNA fragmentation index values are associated with a higher pregnancy rate ( spontaneous and with assisted reproductive technique ) . We suggest that varicocelectomy should be considered in infertile men with palpable varicocele , abnormal semen analysis and no major female factors BACKGROUND Varicocele is the most common correctable cause of infertility . We analyzed the outcomes of single incision laparoscopic varicocelectomy ( SIL-V ) in comparison with conventional transperitoneal varicocelectomy ( CTL-V ) . METHODS Patients with clinical ly palpable varicocele treated by laparoscopic varicocelectomy  were r and omly allocated into two groups : SIL-V and CTL-V group . The primary outcome measures were improvement in semen parameters and resolution of testicular pain . Secondary outcome measures included operating time , postoperative pain scores , time to return to normal activity , patient satisfaction and postoperative complications . RESULTS Eighty patients completed the study . No vascular or intestinal complications occurred during both procedures . All patients were discharged 24 h postoperatively . The parameters measuring the success of varicocelectomy had improved for the majority of patients with no significant difference between the two groups . There was significantly longer operating time in SIL-V group ( 44.6 ± 5.4 min ) than in CTL-V group ( 41.3 ± 8.5 min ) ( P = 0.03 ) . The difference in operating time was lost when bilateral procedures were compared ( P = 0.21 ) . The mean VAS scores for pain at 3 , 24 and 48 h postoperatively were significantly lower in SIL-V group ( P = 0.02 , P = 0.03 and P < 0.001 respectively ) . Time to return to normal activity was significantly shorter in SIL-V ( P < 0.001 ) . Patient satisfaction was significantly higher in SIL-V group ( P < 0.01 ) . Postoperative complications were comparable in both groups . CONCLUSION SIL-V is a safe and effective straightforward alternative to the well-established and accepted CTL-V. The tendency toward decreased postoperative pain , rapid return to normal activity and the high patients ' satisfaction rate regarding cosmetic results are potential benefits of SIL-V procedure . CLINICAL TRIAL ( NCT02335385 ) There is evidence from retrospective studies that varicocelectomy can improve sperm DNA damage in infertile men with a clinical varicocele . The objective of this prospect i ve study was to examine further the effect of varicocelectomy on sperm chromatin and DNA integrity . We evaluated a consecutive series of infertile men ( n = 25 ) who underwent microsurgical varicocelectomy for treatment of clinical varicocele . We examined conventional sperm parameters and sperm chromatin structure assay parameters ( percentage DFI -- DNA fragmentation index and percentage HDS -- high DNA stainability , an index of chromatin compaction ) before and 4 and 6 months after microsurgical varicocelectomy .  Sperm DNA integrity improved significantly after surgery ( percentage DFI decreased from 18 ± 11 % before surgery to 10 ± 5 % , and 7 ± 3 % , at 4 and 6 months after surgery respectively ) . Sperm chromatin compaction also improved significantly after surgery ( percentage HDS decreased from 11 ± 7 % before surgery to 8 ± 6 % , and 7 ± 5 % , at 4 and 6 months after surgery , respectively ) . Sperm concentration and progressive motility improved after surgery , although the differences were not statistically significant when compared with that before surgery . The data show that varicocelectomy is associated with an improvement in sperm DNA integrity and chromatin compaction . These findings support the concept that correction of a varicocele can improve spermatogenesis , particularly spermiogenesis ( the stage in spermatogenesis where compaction and stability of the sperm DNA and chromatin occur ) OBJECTIVE To review the effect of assisted reproductive technology ( ART ) on perinatal outcomes , to provide guidelines to optimize obstetrical management and counselling of Canadian women using ART , and to identify areas specific to birth outcomes and ART requiring further research . OPTIONS Perinatal outcomes of ART pregnancies in subfertile women are compared with those of spontaneously conceived pregnancies . Perinatal outcomes are compared between different types of ART . OUTCOMES This guideline discusses the adverse outcomes that have been recorded in association with ART , including obstetrical complications , adverse perinatal outcomes , multiple gestations , structural congenital abnormalities , chromosomal abnormalities , imprinting disorders , and childhood cancer . EVIDENCE The Cochrane Library and MEDLINE were search ed for English- language articles from 1990 to February 2005 , relating to assisted reproduction and perinatal outcomes . Search terms included assisted reproduction , assisted reproductive technology , ovulation induction , intracytoplasmic sperm injection ( ICSI ) , embryo transfer , and in vitro fertilization ( IVF ) . Additional publications were identified from the bibliographies of these articles as well as the Science Citation Index . Studies assessing  gamete intrafallopian transfer ( GIFT ) and  zygote intrafallopian transfer ( ZIFT ) were excluded since they are rarely used in Canada . All study types were review ed . R and omized controlled trials were considered evidence of the highest quality , followed by cohort studies . Key studies and supporting data for each recommendation are summarized with evaluative comments and referenced . VALUES The evidence collected was review ed by the Genetics Committee and the Reproductive Endocrinology Infertility Committee of the Society of Obstetricians and Gynaecologists of Canada ( SOGC ) and quantified using the Evaluation of Evidence Guidelines developed by the Canadian Task Force on the Periodic Health Examination . BENEFITS , HARMS , AND COSTS The type and magnitude of benefits , harms , and costs expected for patients from guideline implementation . This guideline has been review ed by the Genetics Committee and the Reproductive Endocrinology and Infertility Committee , and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada and the Board of the Canadian Fertility and And rology Society . RECOMMENDATIONS 1 . Spontaneous pregnancies in untreated infertile women may be at higher risk for obstetrical complications and perinatal mortality than spontaneous pregnancies in fertile women . Further research is required to clarify the contribution of infertility itself to adverse obstetrical and perinatal outcomes . ( II-2A ) 2 . All men with severe oligozoospermia or azoospermia should be offered genetic/ clinical counselling for informed consent and offered karyotyping for chromosomal abnormalities before attempting IVF-ICSI . They should be made aware of the availability of tests for Y chromosome microdeletion . Some patients may consider the option of donor insemination . ( II-3B ) 3 . Couples exploring IVF-ICSI when the man has obstructive azoospermia should be offered genetic/ clinical counselling for informed consent and offered genetic testing for alterations in genes associated with cystic fibrosis ( CF ) before attempting IVF-ICSI . ( II-2A ) 4 . Pregnancies achieved by ovarian stimulation with gonadotropins and intrauterine insemination are at higher risk for perinatal complications , and close surveillance during pregnancy should be considered . It remains unclear if these increased risks are attributable to the underlying infertility , characteristics of the infertile couple , or use of assisted reproductive techniques . Multiple gestations remain a significant risk of gonadotropin treatment . ( II-2A ) 5 . Pregnancies achieved by IVF with or without ICSI are at higher risk for obstetrical and perinatal complications than spontaneous pregnancies , and close surveillance during pregnancy should be considered . It remains unclear if these increased risks are attributable to the underlying infertility , characteristics of the infertile couple , or use of assisted reproductive techniques . ( II-2A ) 6 . Women undergoing ART should be informed about the increased rate of obstetrical interventions such as induced labour and elective Caesarean delivery . ( II-2A ) 7 . Couples suffering from infertility who are exploring treatment options should be made aware of the psychosocial implication s of ART . Further research into the psychosocial impact of ART is needed . ( II-2A ) 8 . Singleton pregnancies achieved by assisted reproduction are at higher risk than spontaneous pregnancies for adverse perinatal outcomes , including perinatal mortality , preterm delivery , and low birth weight , and close surveillance during pregnancy should be available as needed . ( II-2A ) 9 . A significant risk of ART is multiple pregnancies .  Infertile couples need to be informed of the increased risks of multifetal pregnancies . Although dichorionic twins are most common , the incidence of monochorionic twins is also increased . Risks of multiple pregnancies include higher rates of perinatal mortality , preterm birth , low birth weight , gestational hypertension , placental abruption , and placenta previa . Perinatal mortality in assisted conception twin pregnancies appears to be lower than in spontaneously conceived twin pregnancies . ( II-2A ) 10 . When multifetal reduction is being considered for high-order multiple pregnancies , psychosocial counselling should be readily available . Careful surveillance for fetal growth problems should be undertaken after multifetal reduction . ( II-2A ) 11 . To reduce the risks of multiple pregnancies associated with ART and to optimize pregnancy rates , national guidelines should be developed on the number of embryos replaced according to characteristics such as patient 's age and grade of embryos . ( II-2A ) 12 . Further epidemiologic and basic science research is needed to help determine the etiology and extent of the increased risks to childhood and long-term growth and development associated with ART . ( II-2A ) 13 . Discussion of options for prenatal screening for congenital structural abnormalities in pregnancies achieved by ART is recommended , including appropriate use of biochemical and sonographic screening . ( II-2A ) 14 . Further epidemiologic and basic science research is needed to help determine the etiology and extent of the increased risks of congenital abnormalities associated with ART . ( II-2A ) 15 . Couples considering IVF-ICSI for male-factor infertility should receive information , and if necessary formal genetic counselling , about the increased risk of de novo chromosomal abnormalities ( mainly sex chromosomal anomalies ) associated with their condition . Prenatal diagnosis by chorionic villus sampling ( CVS ) or amniocentesis should be offered to these couples if they conceive . ( II-2A ) 16 . Further epidemiologic and basic science research is needed to help determine the etiology and extent of the increased risks of chromosomal abnormalities associated with ART . ( II-2A ) 17 . Discussion of options for prenatal screening and testing for aneuploidy in pregnancies achieved by ART , adapted for maternal age and number of fetuses , is recommended , including appropriate use of biochemical and sonographic screening . ( II-2A ) 18 . The precise risks of imprinting and childhood cancer from ART remain unclear but can not be ignored . Further clinical research , including long-term follow-up , is urgently required to evaluate the prevalence of imprinting disorders and cancers associated with ART . ( II-2A ) 19 . The clinical application of preimplantation genetic diagnosis must balance the benefits of avoiding disease transmission with the medical risks and financial burden of in vitro fertilization . Further ethical discussion and clinical research is required to evaluate appropriate indications for preimplantation genetic diagnosis . ( III-B ) We examined the effect of 12 weeks of daily oral administration of pentoxifylline with zinc and folic acid on the semen quality of 36 men with varicocele-associated infertility in an open , uncontrolled study . After 4 weeks of treatment , the proportion of morphologically normal sperm cells was significantly increased ; these changes persisted until at least 4 weeks after the end of treatment Varicocele is among the most common problems which may lead to male infertility . Spermatogenesis is impaired as a consequence of this vascular defect , through mechanisms that are not well described . This study aim ed to evaluate serum hormonal level ( inhibin B , FSH and testosterone ) and seminal plasma antioxidant defence levels after folic acid and zinc sulphate administration in varicocelectomised patients . Participants were r and omly allocated to four experimental groups . Our r and omisation schedule was as follows : zinc sulphate/folic acid , folic acid , zinc sulphate and placebo . The patients underwent varicocelectomy , before which a blood and semen sample were obtained and also three and six months after varicocelectomy for evaluation of blood hormonal level ( FSH , testosterone , inhibin B ) and seminal oxidative stress status ( nitric oxide , superoxide dismutase , total antioxidant capacity ) . Patients in different groups took orally one capsule per day after dinner following varicocelectomy for 6 months . A significant rise in peripheral blood inhibin B and seminal plasma activity was detected in the zinc sulphate/folic acid group after 6 months . The present clinical trial indicates a change in the hormonal status of varicocelectomised patients following long‐term administration of zinc sulphate and folic acid Differences in disease prevalence , clinical manifestations , and health outcomes exist between men and women . Sources for this variation range from biological differentiation at the cellular level to behavioral differences influenced by societal gender norms . Typically , biologically based differences between men and women are called sex differences , whereas gender differences describe health differences related , at least in part , to societal constructs of gender ( 13 ) . For example , biological events unique to women , such as pregnancy and menopause , are probably associated with sex differences in occurrence of certain conditions or in response to some medical therapies ( 48 ) . Gender differences probably exist in health-related perceptions and behaviors for women and men with medical conditions that are prevalent for both sexes ( for example , heart disease and chronic pain ) ( 9 –16 ) . Although sex and gender differences are theoretically distinct , they remain difficult to disentangle when differences between men and women in health outcomes and treatment effectiveness are being examined . For this reason , and for brevity , we hereafter refer to sex and gender differences collectively as sex effects . In the past 2 decades , recognition of the importance of sex effects for health outcomes and treatment heterogeneity has been growing . Beginning in 1993 , the National Institutes of Health has issued policies requiring the inclusion of women and minorities in all clinical research and trial design s with valid analysis of sex effects or differences between racial and ethnic groups ( 17 , 18 ) . Since then , the inclusion of women in clinical trials has increased ( 19 , 20 ) , and sex effects have been identified for medications , such as nicotine replacement therapy , analgesics , and aspirin ( 13 , 14 , 21 ) . Recently , sex effects in adverse reactions led to sex-specific dosage recommendations for a widely used sedative ( 7 ) . Despite this progress , representation of women in clinical studies remains inadequate for many conditions ( 22 ) . Further , published clinical trials infrequently report sex effects or discuss the appropriateness of sex-specific analyses ( 19 , 20 , 23 ) . To advance the clinical evidence base and improve health outcomes for women , clinical research must include adequate numbers of women , appropriately conduct sex-specific analyses , and consistently report sex effects . Systematic review s ( SRs ) are a key source of information for clinicians , research ers , and guideline panels . By synthesizing the overall body of evidence for key clinical and research questions , SRs could potentially make a unique contribution to the evaluation of sex effects . To our knowledge , however , the reporting of sex effects by SRs has not been previously examined . Here , we use evidence mapping to systematic ally evaluate the reporting of sex effects by SRs examining a diverse set of interventions for chronic conditions common to women ( that is , depression , diabetes , and chronic pain ) . Evidence mapping is an emerging approach that describes key characteristics of studies for a broad area of medicine ( 2426 ) . Our evidence map addresses the volume and characteristics of eligible SRs , including the representation of women in primary studies , whether and how review s reported sex effects , and findings about sex effects . Methods This work was part of a larger report for the Veterans Health Administration ( VHA ) Evidence -based Synthesis Program ( ESP ) . The complete technical report is available online ( www.hsrd . research .va.gov/publications/esp ) and includes additional information on our methods . We focused on SRs to determine the reporting of sex effects , provide high-level information about the volume of current clinical evidence , and summarize information about actual sex effects . Prioritization of Conditions for Inclusion We used forced-ranking prioritization ( 27 ) with our VHA stakeholders to determine our conditions of interest . These stakeholders included representatives from the Health Services Research & Development Center for the Study of Healthcare Innovation , Implementation and Policy ; Health Services Research & Development Women 's Health Research Network ; Women 's Health Research in the Office of Research & Development ; Women 's Health Services ; and Mental Health Services . We initially selected 34 conditions ( Appendix Table 1 ) based on disease prevalence in women , disease burden in women , availability and breadth of effective treatments for men or women , and women veterans ' priorities for gender-specific care . Stakeholders ranked this initial set of conditions , discussed the rankings , and reranked conditions that initially received intermediate priority rankings . After 2 rounds of iterative prioritization , the following conditions were selected : depressive disorders , type 2 diabetes mellitus , and chronic pain ( that is , chronic low back pain , fibromyalgia , and chronic knee pain due to osteoarthritis ) . Appendix Table 1 . Conditions Presented to Stakeholders for Prioritization * Data Sources and Search es In collaboration with an expert reference librarian , we search ed PubMed and Cochrane Data base of Systematic Review s to identify eligible SRs published after 1 October 2009 through 31 October 2014 for depression , 13 February 2015 for diabetes , and 27 February 2015 for chronic pain . Search strategies used Medical Subject Headings and free-text terms for the conditions of interest , eligible interventions , and SRs ( Appendix Table 2 ) . We restricted the search to the past 6 years because SRs are typically out date d within 5 years of publication ( 28 ) , and our goal was to describe the current state of the clinical literature . In addition to electronic search ing , we screened published review s of review s for eligible articles . Appendix Table 2 . Search Strategies Study Selection and Quality Assessment Eligible SRs evaluated interventions in several broad categories ( that is , medications , behavioral interventions , supervised exercise , and quality improvement or organizational interventions ) . We also included condition-specific interventions , such as bariatric surgery for diabetes . Review s that evaluated mixed conditions or multiple interventions must have reported results separately for at least 1 eligible condition or intervention . We included review s of interventions in any setting , with any type of active or inactive comparator , and with any duration of follow-up . Detailed inclusion and exclusion criteria are provided in Appendix Table 3 . Appendix Table 3 . Detailed Inclusion and Exclusion Criteria for Review Eligibility Two investigators screened citations for eligibility , and citations that were considered to be relevant by either person were retained for full-text review . Full-text articles were review ed by 2 investigators , and disagreements were resolved through discussion or adjudicated by a third person . Formal assessment of review quality was beyond the scope of this project . However , we noted whether review s originated from organizations known for high- quality review s ( that is , Cochrane Collaboration , Agency for Healthcare Research and Quality Evidence -based Practice Centers , and VHA ESP ) . For review s reporting sex effects , we also assessed industry funding and whether statistical power was considered . Data Abstract ion Data were abstract ed by 1 investigator and review ed by a second person . Disagreements were resolved by discussion or by a third review er . Abstract ed data included the analysis method ( that is , qualitative synthesis , meta- analysis , network meta- analysis , or individual-patient data [ IPD ] meta- analysis ) ; clinical conditions ; interventions ; main outcomes ; number and design of primary studies ( for example , r and omized , controlled trials [ RCTs ] or observational cohorts ) ; proportion of women in the included primary studies ; and if sex effects were part of the study aims , analysis plan , or results . For review s reporting sex effects , we also recorded the number of primary studies used for sex-specific analyses , effect estimates , and the method used ( for example , metaregression , subgroup analysis , or IPD meta- analysis ) . All eligible review s on depressive disorders and chronic pain conditions were fully abstract ed . All diabetes review s of nonpharmacologic interventions were also fully abstract ed . For eligible diabetes medication review s ( n= 120 ) , we applied an additional prioritization procedure before full abstract ion . We prioritized review s that examined multiple classes of medications or evaluated a single class of medications when 6 or fewer eligible review s were identified . For SRs evaluating a single class ( > 6 eligible review s were identified ) , we used additional prioritization criteria ( for example , the most recent review published in a high-impact journal or work done by an organization known for high- quality review s ) . The remaining unselected but eligible review s ( n= 58 ) had a keyword text search for sex effects and were fully abstract ed only when this search yielded positive results ( n= 13 ) . Data Synthesis and Analysis of SRs We grouped eligible review s by intervention category and described the overall volume of clinical literature for interventions addressing each condition of interest . We also determined the number of review s reporting sex effects and summarized these results . Time trends for the proportion of these review s were examined for depression and diabetes . Examination of Primary RCTs for Selected Interventions We anticipated that some interventions for each condition would have few or no eligible SRs that addressed sex effects . Thus , for a subset of interventions for each condition , we evaluated primary RCTs to determine the feasibility of conducting a future review to evaluate sex effects . Specifically , we examined  quality improvement interventions and psychotherapy for depression ; diet , physical activity , and culturally tailored psychoeducation for diabetes ; behavioral interventions for chronic low back pain ; and exercise interventions PURPOSE We review the long-term results of varicocele repair , and compare the complication rates of varicocelectomy techniques according to optical magnification use in adolescents with varicocele at a single university hospital . MATERIAL S AND METHODS We prospect ively studied 100 males 7 to 19 years old with clinical palpable varicocele . Of the patients 52 ( 52 % ) underwent left unilateral varicocelectomy  and 48 ( 48 % ) underwent bilateral varicocelectomy . Varicocelectomy was performed using a microscope in 49 patients ( 79 sites ) , loupe magnification in 25 ( 35 sites ) and no magnification in 26 ( 34 sites ) using either a subinguinal or inguinal approach . Postoperative complications were compared in all patients based on technique . Preoperative and postoperative serum hormone values and semen parameters were compared in 33 patients . RESULTS Mean postoperative followup was 30.4 + /- 13.06 months ( 12 to 65 ) . Total motile sperm count increased from 22.6 million + /- 5.16 million to 64.53 million + /- 12.3 million postoperatively , which was statistically significant ( p = 0.002 ) . Postoperative recurrence rates were 0 % in cases managed by microsurgical varicocelectomy , 2.9 % in those where loupe magnification was used and 8.8 % in those where no magnification was used . Postoperative hydrocele rates in these cases were 0 % , 2.9 % and 5.9 % , respectively . The highest rates of recurrence and hydrocele were observed in cases where no magnification was used , compared to those managed by microsurgery ( p = 0.03 and p = 0.116 , respectively ) . CONCLUSIONS Adolescent varicocele repair improves semen parameters and is a safe method with low recurrence and low complication rates . Our study suggests that the postoperative complication rate significantly decreases with use of higher magnification , such as microscopy . Microsurgical varicocele repair is the best technique with the lowest postoperative rates of recurrence and hydrocele in the treatment of adolescent varicoceles INTRODUCTION Adolescent males with varicoceles present a dilemma for surveillance and treatment . Testicular volumetrics have not been shown to predict SA outcomes . Serial SAs are thus recommended in asymptomatic adolescent males with varicoceles and normal testicular development , but the natural history of semen parameters is unknown . OBJECTIVE To explore the natural history of semen parameters in adolescent boys with a left varicocele under active surveillance . STUDY DESIGN Adolescents with an asymptomatic unilateral left varicocele , Tanner V development , normal testicular volumes , and an initial SA were retrospectively review ed in a single-institution prospect ively followed cohort .  Total motile count ( TMC ) was calculated . A cutoff of TMC Z 20 million was used to dichotomize SA results into " normal " or " poor . " Those with poor SA were offered repeat SA . Cumulative probabilities of normal TMC over successive rounds of SA were calculated . Bivariate models were used to explore associations of a second consecutive poor TMC with age and varicocele grade . RESULTS A total of 216 patients provided an initial SA between 1992 and 2015 . We excluded 17 for a history of cryptorchidism or incomplete SA data for a final cohort of 199 patients with median follow-up of 3.3 years ( interquartile range 1.5 - 5.6 years ) . The  mean age at initial SA was 17.9 years ( range 14.8 - 21.8 years ) . One hundred and nine out of 199 had an initial normal TMC . Of the 90 out of 199 with an initially poor TMC , 51 had repeat SA and 24 of the 51 patients improved to normal TMC . Of the 27 patients with two consecutive poor TMCs , 15 had a third SA and five out of 15 improved to normal TMC . Thus , cumulatively , 55 % , 67 % , and 69 % of all patients had a normal TMC after an initial , second , and third SA , respectively . However , fewer patients in each round of SA normalized their TMC ( Figure ) . Neither age nor varicocele grade was associated with a second consecutive poor TMC . DISCUSSION Two-thirds of Tanner V boys with an uncorrected varicocele and normal testicular volumes achieve a normal TMC regardless of varicocele grade or age . Despite Tanner V development , 47 % with an initial " poor " SA will improve to normal status without surgery . However , a small subgroup of patients will have persistently poor TMC and thus should be targeted in future research for timely intervention . CONCLUSION Semen parameters improve over time . SA should be followed and repeated at least once in symptomatic Tanner V boys with varicoceles Glutathione therapy was used for 2 months in a placebo-controlled double-blind cross-over trial of 20 infertile patients with dyspermia associated with unilateral varicocele ( VAR ) or germ-free genital tract inflammation ( INF ) . The patients received either glutathione ( group 1 ) or placebo ( group 2 ) for 2 months , then they crossed over to the alternative treatment for a further 2 months . The patients were r and omly and blindly assigned to treatment ( one i.m . injection every other day of either 600 mg glutathione or an equal volume of a placebo preparation ) . The st and ard semen analysis and the computer-assisted sperm motility analyses were carried out before treatment and during the trial . Statistical cross-over analysis , case-control study and treatment efficacy test were carried out on groups 1 and 2 and differences in the effects of therapy between VAR and INF patients with varicocele or inflammation were tested . Glutathione therapy demonstrated a statistically significant positive effect on sperm motility , in particular on the percentage of forward motility , the kinetic parameters of the computerized analysis and on sperm morphology . The findings of this study indicate that glutathione therapy could represent a possible therapeutical tool for both of the selected and rological pathologies STUDY QUESTION Is there a relationship between DNA damage and numerical chromosome abnormalities in the sperm of infertile patients ? SUMMARY ANSWER A strong link between DNA fragmentation and the presence of numerical chromosome abnormalities was detected in human sperm . Chromosomally abnormal spermatozoa were more likely to be affected by DNA fragmentation than those that were chromosomally normal . WHAT IS KNOWN ALREADY Several studies have described the presence of elevated levels of DNA damage or chromosome defects in the sperm of infertile or subfertile men . However , the nature of the relationship between sperm DNA damage and chromosome abnormalities is poorly understood . The fact that some assisted reproductive techniques have the potential to allow abnormal spermatozoa to achieve oocyte fertilization has led to concerns that pregnancies achieved using such methods may be at elevated risk of genetic anomalies . STUDY DESIGN , SIZE , DURATION For this prospect i ve study , semen sample s were collected from 45 infertile men . PARTICIPANTS , SETTING , METHODS Sample s were assessed for DNA fragmentation using the Sperm Chromatin Dispersion Test ( SCDt ) and for chromosome abnormalities using multi-colour fluorescence in situ hybridization ( FISH ) with probes specific to chromosomes 13 , 16 , 18 , 21 , 22 , X and Y. Additionally , both parameters were assessed simultaneously in 10 of the sample s using a protocol combining SCDt and FISH . MAIN RESULTS AND THE ROLE OF CHANCE A significant correlation between the proportion of sperm with a numerical chromosome abnormality and the level of DNA fragmentation was observed ( P < 0.05 ) . Data from individual spermatozoa subjected to combined chromosome and DNA fragmentation analysis indicated that chromosomally abnormal sperm cells were more likely to display DNA damage than those that were normal for the chromosomes tested ( P < 0.05 ) . Not only was this association detected in sample s with elevated levels of numerical chromosome abnormalities , but it was also evident in sample s with chromosome abnormality rates in the normal range . LIMITATIONS , REASONS FOR CAUTION The inability to assess the entire chromosome complement is the main limitation of all studies aim ed at assessing numerical chromosome abnormalities in sperm sample s. As a result , some of the sperm classified as ' chromosomally normal ' may be aneuploid for chromosomes that were not tested . WIDER IMPLICATION S OF THE FINDINGS During spermatogenesis , apoptosis ( a process that involves active DNA degradation ) acts to eliminate abnormal sperm . Failure to complete apoptosis may explain the coincident detection of aneuploidy and DNA fragmentation in some spermatozoa . In addition to shedding light on the biological mechanisms involved in the processing of defective sperm , this finding may also be of clinical relevance for the identification of patients at increased risk of miscarriage or chromosomally abnormal pregnancy . In some instances , detection of elevated sperm DNA fragmentation may indicate the presence of chromosomal abnormalities . It may be worth considering preimplantation genetic screening ( PGS ) of embryos produced using such sample s in order to minimize the risk of aneuploidy
Taken together , the clinical work to date suggests that the highest fertility rates and the lowest complication rates are associated with the microsurgical subinguinal surgical approach to varicocelectomy .
Abstract Despite being first described two thous and years ago , the varicocele remains a controversial multifaceted disease process with numerous biological consequences including infertility , hypogonadism , and chronic orchidalgia .
The underlying mechanisms remain poorly understood and likely include hypoxia , oxidative stress , hyperthermia , anatomical aberrations , and genetics as primary components .
Despite a high prevalence amongst asymptomatic fertile men , varicoceles paradoxically also represent the most common correctable cause for male infertility .
In this systematic review we discuss the rich historical aspects of the varicocele and the contemporary data regarding its clinical manifestations .
We performed a systematic literature review with the goal of comparing outcomes and complication rates of each of the major surgical approaches as they relate to infertility and pain .