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Varicocele in the ICIS Era


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Varicocele in the ICIS Era

  1. 1. Insight’12 – Lite, Coimbatore, India – May 2012 Sandro Esteves, MD, PhD Director, ANDROFERT Center for Male Reproduction and Infertility Campinas, BRAZIL
  2. 2. Varicocee Varicocele: Prevalence • 15% male population • 35% of male infertility casesEsteves, 2
  3. 3. Varicocele: Physical ExaminationEsteves, 3
  4. 4. Varicocele: Use of Pencil- probe DopplerEsteves, 4
  5. 5. Courtesy of Prof. Juan Alvarez Varicocele: Pathophysiology Epididymis Spermatogonia Seminiferous Tubules Spermatocytes Vas Deferens Early spermatids Sertoli Elongated Cell spermatids Mature spermatozoa ROS-induced DNA damage Alvarez and Sakkas, Fertil Steril, 2010
  6. 6. Varicocele: Treatment Surgical Treatment • Indication for Treatment: Clinical (palpable) varicocele and Abnormal semen analysis resultsEsteves, 6
  7. 7. Surgical Treatment of Varicocele Technique Internal External Recurrence Hydrocele Spontaneous Spermatic Spermatic Rate Formation Pregnancy Vein Vein Rate Rate Ligation Ligation Retroperitoneal Yes No 7-35% 6-10% 25-55% High-Ligation (Palomo) Laparoscopic Yes No 2-7% 0-9% 14-42% Embolization Yes No 2-24% NR 20-40% Macroscopic Yes Yes 0-37% 7% 34-39% Inguinal (Ivanissevich) Microscopic Yes Yes 0-0.3% 0-1.6% 33-56% Inguinal or Subinguinal45,51,54,55Esteves, 7
  8. 8. Miyaoka & Esteves. Critical appraisal on the role of varicocele in male infertility.Esteves, 8 Adv Urol 2012; Epub
  9. 9. Surgical Treatment of Varicocele Fertility Restoration Spontaneous PregnancyEsteves, 9
  10. 10. Varicocelectomy for Fertility Restoration Fertil Steril 2007;88:639–48.Esteves, 10
  11. 11. Implications for Practice • Varicocele treatment Surgical Treatment • Effect • Decrease seminal oxidative stress • Improve sperm DNA integrity • Improve semen parameters • Increase the likelihood of spontaneous and assisted pregnancyEsteves, 11
  12. 12. Surgical Treatment of Varicocele • It can improve success of ART Fertility Improvement Fertility ICSI Restoration Outcomes Spontaneous Pregnancy Fertility Improvement Sperm Retrieval in AzoospermiaEsteves, 12
  13. 13. Varicocele Repair Before ICSI Clinical Outcome of Intracytoplasmic Sperm Injection in Infertile Men With Treated and Untreated Clinical Varicocele SC Esteves, FV Oliveira, RP Bertolla. ANDROFERT, Center for Male Reproduction, Campinas, BRAZIL and Division of Urology, São Paulo Federal University, São Paulo, BRAZIL. The Journal of Urology Vol. 184,1442-1446, October 2010 Total Number of Motile Microsurgical Sperm (x106) varicocele repair prior 15.4 to ICSI (N=80) P<0.01 6.7 ICSI in the presence of varicocele (N=162)Esteves, 13 Pre-op Post-op
  14. 14. Varicocele and ICSI Outcomes Treated Varicocele Untreated Varicocele 78%* 66% *P<0.05 46%* 31% 31% 22% Fertilized Eggs Live Birth (%) Miscarriage (%) (%2PN) Odds ratio 1.87 0.43 95% CI 1.08 - 3.25 0.22 – 0.84 P-value 0.03 0.01 Esteves SC, Oliveira FV, Bertolla RP. Clinical Outcome of ICSI in Infertile Men withEsteves, 14 Treated and Untreated Clinical Varicocele. J Urol 2010;184:1442-1446
  15. 15. Varicocele Repair Before Sperm Retrieval Sperm Retrieval and Intracytoplasmic Sperm Injection in Men With Nonobstructive Azoospermia, and Treated and Untreated Varicocele K Inci, M Hascicek, O Kara et al. Department of Urology, School of Medicine, Hacettepe University, Ankara, Turkey. The Journal of Urology Vol. 182,1500-1505, October 2009 Successful Sperm Retrieval Microsurgical Rate varicocele repair prior to sperm retrieval ICSI OR: 2.63 (95% CI: 1.05-6.60; P=0.03) (N=66) 53% 30% Sperm Retrieval in the presence of varicocele (N=30) Treated VaricoceleEsteves, 15 Untreated Varicocele
  16. 16. Take-home Messages Evidence for a Positive Impact in the Surgical Treatment of Clinical Varicoceles : 1. Increase the likelihood of spontaneous conception in men with mild/moderate abnormal semen parameters. 2. Increase the odds of live birth in subgroups of men with severe oligozoospermia undergoing ICSI. 3. Increase the chance of having a successful sperm retrieval in the subgroup of patients with non-obstructive azoospermia.Esteves, 16