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Jonathan P Jarow - One of the best experts on this subject based on the ideXlab platform.
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insight on pathogenesis of Varicoceles relationship of Varicocele and body mass index
Urology, 2006Co-Authors: Matthew E Nielsen, Jonathan P Jarow, Stephen Zderic, Stephen J FreedlandAbstract:Objectives Varicoceles, present in 15% to 20% of men, are the most common abnormal finding among men presenting with infertility, yet controversy exists regarding their etiology. Anecdotal experience suggests that Varicoceles are more prevalent in lean men, supporting the “nutcracker” effect of the superior mesenteric artery compressing the left renal vein over the aorta. We examined this hypothesis in a large adult population. Methods A total of 2106 men were evaluated for infertility or erectile dysfunction from 1990 to 1996. The men were examined for the presence and severity of a Varicocele. The association between age, height, body mass index, year of evaluation, and reason for consultation and the presence and severity of a Varicocele was examined using logistic regression analysis. Results The mean age was 47 years (range 18 to 85), and the median body mass index was 26.4 kg/m2 (range 15.4 to 53.3). A Varicocele was present in 398 men (18.9%). Stratified by grade, 59 (14.8%) were grade III, 155 (38.9%) were grade II, and 184 (46.2%) were grade I. The prevalence of Varicoceles in the erectile dysfunction group (12.7%) was significantly less (P <0.001) than in the infertile group (32.2%). Multivariate logistic regression analysis revealed a statistically significant inverse relationship between body mass index and the presence of a Varicocele. Conclusions Varicoceles were less likely to be diagnosed among obese men. Although this suggests that the “nutcracker” phenomenon or other biophysical effects of increased adiposity may play a role in the pathogenesis, other factors could not be excluded as contributing to our findings.
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Insight on pathogenesis of Varicoceles: Relationship of Varicocele and body mass index
Urology, 2006Co-Authors: Matthew E Nielsen, Stephen Zderic, Stephen J Freedland, Jonathan P JarowAbstract:Objectives Varicoceles, present in 15% to 20% of men, are the most common abnormal finding among men presenting with infertility, yet controversy exists regarding their etiology. Anecdotal experience suggests that Varicoceles are more prevalent in lean men, supporting the “nutcracker” effect of the superior mesenteric artery compressing the left renal vein over the aorta. We examined this hypothesis in a large adult population. Methods A total of 2106 men were evaluated for infertility or erectile dysfunction from 1990 to 1996. The men were examined for the presence and severity of a Varicocele. The association between age, height, body mass index, year of evaluation, and reason for consultation and the presence and severity of a Varicocele was examined using logistic regression analysis. Results The mean age was 47 years (range 18 to 85), and the median body mass index was 26.4 kg/m2 (range 15.4 to 53.3). A Varicocele was present in 398 men (18.9%). Stratified by grade, 59 (14.8%) were grade III, 155 (38.9%) were grade II, and 184 (46.2%) were grade I. The prevalence of Varicoceles in the erectile dysfunction group (12.7%) was significantly less (P
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effects of Varicocele on male fertility
Human Reproduction Update, 2001Co-Authors: Jonathan P JarowAbstract:Varicoceles are vascular lesions of the pampiniform plexus and are the most common identifiable abnormality found in men being evaluated for infertility. Despite the long history associated with Varicoceles, there remains much controversy regarding their diagnosis and management. The purpose of this manuscript is to address three of the most pressing controversies: (i) the association of Varicoceles with male infertility, (ii) whether Varicoceles exert a progressive deleterious effect and (iii) the relationship of Varicocele size and outcome following Varicocele repair. The current literature is reviewed in an effort to answer these questions. Based upon this analysis, conclusions can be drawn regarding the best management of Varicoceles in subfertile men, adolescents, young fertile men and men with subclinical Varicoceles. Although there remain many controversies due to a paucity of data, there appears to be a significant difference between adults and adolescents with respect to a progressive deterioration of semen parameters and it is clear that subclinical Varicoceles do not play a major role in male infertility.
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Ultrasonographic diagnosis of Varicoceles.
Fertility and sterility, 1993Co-Authors: L. Andrew Eskew, Nat E. Watson, Neil T. Wolfman, Robert E. Bechtold, Eric S. Scharling, Jonathan P JarowAbstract:Objective To assess the ability of color duplex scrotal ultrasonography to detect subclinical Varicoceles and confirm the diagnosis of clinical Varicoceles. Design Physical examination, color duplex scrotal ultrasonography and internal spermatic venography was performed on 64 testicular units in 33 men. Setting Male fertility center. Patients Two hundred sixty-two consecutive men being evaluated for male factor infertility of whom 33 agreed to undergo venography. Main Outcome Measures Ultrasonographic measurement of scrotal vein diameter of patients in the supine and upright position, before and during valsalva maneuver, and scrotal vein blood flow reversal with valsalva maneuver was compared with the findings of Varicocele by physical examination and venography. Results The best predictor of a Varicocele was internal spermatic vein diameter, and the best overall performance of ultrasonography was achieved with the patient at rest in the supine position. The best cutoff point for venous diameter for a clinical Varicocele was 3.6 mm and 2.7 mm for a subclinical Varicocele, but the overall accuracy was only 63%. Conclusions Confirmatory studies are needed to support the ultrasonographic diagnosis of Varicoceles before considering surgical repair.
Marc Goldstein - One of the best experts on this subject based on the ideXlab platform.
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when is a Varicocele repair indicated the dilemma of hypogonadism and erectile dysfunction
Asian Journal of Andrology, 2016Co-Authors: Ali A Dabaja, Marc GoldsteinAbstract:In the past, the indications for Varicocelectomy are primarily for infertility with abnormal semen parameters, testicular hypotrophy/atrophy in adolescents, and/or pain. The surgical treatment of Varicocele for hypogonadism is controversial and debated. Recently, multiple reports in the literature have suggested that Varicocele is associated with hypogonadism and Varicocele repair can increase testosterone levels. Men with hypogonadal symptoms should have at least two serum testosterone levels. Microsurgical Varicocelectomy may be beneficial for men with clinically palpable Varicoceles with documented hypogonadism. In this review, we summarize the most recent literature linking Varicocele to hypogonadism and sexual dysfunction and the impact of repair on serum testosterone levels. We performed a search of the published English literature. The key words used were "Varicocele and hypogonadism" and "Varicocele surgery and testosterone." We included published studies after 1998. We, also, evaluated the effect of surgery on the changes in the serum testosterone level regardless of the indication for the Varicocele repair.
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alternate indications for Varicocele repair non obstructive azoospermia pain androgen deficiency and progressive testicular dysfunction
Fertility and Sterility, 2011Co-Authors: Peter N Schlegel, Marc GoldsteinAbstract:Varicocele repair is indicated for infertile men with clinical Varicoceles. Some men with scrotal pain, low testosterone, non-obstructive azoospermia, and who are at risk for testicular dysfunction may also benefit from Varicocelectomy.
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Varicocele as a risk factor for androgen deficiency and effect of repair
BJUI, 2011Co-Authors: Marc Goldstein, Cigdem Tanrikut, James S Rosoff, Richard K Lee, Christian J NelsonAbstract:Study Type – Therapy (case control) Level of Evidence 2b OBJECTIVE • To determine whether men with Varicoceles have lower testosterone levels than those without and to ascertain if testosterone levels increase after Varicocelectomy. PATIENTS AND METHODS • We measured preoperative testosterone levels in 325 men with palpable Varicoceles and in 510 men with vasectomy reversal without Varicoceles who served as a comparison group. • The testosterone levels between groups were compared by age. Of the men with Varicoceles, 200 had data on both pre- and postoperative testosterone levels, which were compared to assess postoperative changes. RESULTS • Men with Varicocele had significantly lower testosterone levels than the comparison group, with mean (sd) levels of 416 (156) vs 469 (192) ng/dL (P < 0.001). This difference persisted when analysed by age. • The testosterone levels significantly increased after repair from 358 (126) to 454 (168) ng/dL (P < 0.001). • Of the 70% of patients with postoperative improvement in testosterone levels, the mean (sd) increase in testosterone was 178 (142) ng/dL. The percentage change in testosterone levels was: 30% had no increase, 41% increased by ≤50%, 19% increased between by 51–100%, and 10% increased by >100%. • There was no association between change in testosterone level and age, laterality of Varicocele, or Varicocele grade. CONCLUSIONS • Men with Varicoceles had significantly lower testosterone levels than the comparison group of men with vasectomy reversal. • Microsurgical Varicocele ligation resulted in a significant increase in serum testosterone levels in more than two-thirds of men. • These findings suggest that Varicocele is a significant risk factor for androgen deficiency and that repair may increase testosterone levels in men with Varicocele and low testosterone levels.
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Inheritance of Varicoceles.
Urology, 2005Co-Authors: Jay D. Raman, Konstantin Walmsley, Marc GoldsteinAbstract:Objectives To evaluate the inheritance of Varicoceles through examination of first-degree relatives of patients with known Varicoceles. Methods A total of 44 patients with a known Varicocele had available first-degree relatives (n = 62) examined for the presence of a Varicocele between October 1997 and November 2003. An additional cohort of 263 men presenting for vasectomy reversal without a history of subfertility or Varicocele was used as the control group. Varicocele grade and the presence of bilateral Varicoceles were examined as predictive factors for inheritance. Results Of the 62 first-degree relatives of patients with a known Varicocele, 35 (56.5%) had a clinically palpable Varicocele on physical examination. This was significantly greater than the 18 (6.8%) of 263 men in the control group (P
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Medical backgrounder on Varicocele.
Drugs of today (Barcelona Spain : 1998), 2002Co-Authors: Peter T.k. Chan, Marc GoldsteinAbstract:Varicocele is an extremely common entity, present in 15% of the male population. Varicoceles are found in approximately 35% of men with primary infertility but 75%-81% of men with secondary infertility. Mounting evidence clearly demonstrates that Varicocele causes progressive duration-dependent injury to the testis. Larger Varicoceles appear to cause more damage than small Varicoceles and, conversely, repair of large Varicoceles results in greater improvement of semen quality. Varicocelectomy can halt the progressive duration-dependent decline in semen quality found in men with Varicoceles. The earlier the age at which Varicocele is repaired, the more likely is recovery of spermatogenic function. Varicocelectomy can also improve Leydig cell function resulting in increased testosterone levels. The most common complications after Varicocelectomy are hydrocele formation, testicular artery injury and Varicocele persistence or recurrence. The incidence of these complications can be reduced by employing microsurgical techniques, with inguinal or subinguinal operations, and exposure of the external spermatic and scrotal veins. Employment of these advanced techniques of Varicocelectomy provide a safe, effective approach to elimination of Varicocele, preservation of testicular function and, in a substantial number of men, an increase in semen quality and likelihood of pregnancy.
R D Mcclure - One of the best experts on this subject based on the ideXlab platform.
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Varicoceles. Radiologic diagnosis and treatment.
Radiologic clinics of North America, 1991Co-Authors: Barbara E. Demas, Hedvig Hricak, R D McclureAbstract:The association of clinically apparent Varicoceles with male subfertility and infertility has been noted in the urology literature since the late nineteenth century, and surgical ligation of Varicoceles has been considered appropriate therapy in an attempt to improve semen quality and increase fertility for the past 40 years. It has been established by several authors cited herein that Varicocele size does not predict prognosis after ligation reliably. Because subclinical Varicoceles may affect testicular function and histologic characteristics adversely and because age at time of therapy may affect probability of successful enhancement of fertility, the interest of radiologists and urologists has been directed toward diagnosis and treatment of both clinically obvious and clinically occult Varicoceles, particularly in young adult men or adolescent boys. Testicular growth after Varicocele ligation in adolescent boys also suggests a benefit from early intervention. Sonographic evidence of a Varicocele must be correlated with analysis of semen for sperm density, motility, and morphology, as not all patients with Varicoceles are infertile. Although surgical therapy is standard for Varicocele occlusion, fairly extensive evidence exists to show that percutaneous transvenous occlusion of Varicoceles is feasible, safe, and effective, particularly in the setting of Varicocele recurrence after conventional surgical treatment.
Keith Jarvi - One of the best experts on this subject based on the ideXlab platform.
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Varicoceles : The Diagnostic Dilemma
Journal of andrology, 2007Co-Authors: Jason Lee, Saleh Binsaleh, Keith JarviAbstract:Clinical examination of the scrotum remains the most commonly used technique to diagnose Varicoceles. However, scrotal anatomy (eg, thick scrotum, scarring, hydrocele) in some men may make physical examination alone unreliable. In these situations, imaging (eg, ultrasound, Doppler imaging, venography) may be used to diagnose a Varicocele. The dilemma is that there are no widely accepted or used criteria to diagnose a Varicocele based on imaging. This paper reviews the different imaging techniques used and the accuracy of each in diagnosing a Varicocele.
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Loss of left testicular volume in men with clinical left Varicocele: correlation with grade of Varicocele.
Archives of andrology, 1998Co-Authors: Armand Zini, Martin B. Buckspan, D Berardinucci, Keith JarviAbstract:It is reported that a clinical left Varicocele is associated with loss of ipsilateral testicular volume. We have examined the loss of left testicular volume in infertile men with clinical left Varicocele using ultrasound-derived measurements of testicular volume. We have reviewed the testicular volumes, maximum internal spermatic vein diameters, and the clinical reports of 404 men presenting for infertility evaluation at our institution between 1992 and 1996. Men with bilateral or subclinical Varicoceles were excluded from the study. Subclinical Varicoceles were diagnosed by the ultrasonographic demonstration of one or more veins having a maximal diameter of more than 3 mm. In men with clinical left Varicocele, mean left testicular volume was less than right testicular volume (12.7 vs. 13.8 mL, P .05). In men with left Varicocele, the difference between right and left testicular volume (right minus left) increased with increasing Varicocele grade. Our data demonstrate that a left Varicocele is associated with loss of left testicular volume. The results also show that the degree of left testicular hypotrophy is proportional to the clinical grade of the Varicocele.
Peter N Schlegel - One of the best experts on this subject based on the ideXlab platform.
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alternate indications for Varicocele repair non obstructive azoospermia pain androgen deficiency and progressive testicular dysfunction
Fertility and Sterility, 2011Co-Authors: Peter N Schlegel, Marc GoldsteinAbstract:Varicocele repair is indicated for infertile men with clinical Varicoceles. Some men with scrotal pain, low testosterone, non-obstructive azoospermia, and who are at risk for testicular dysfunction may also benefit from Varicocelectomy.
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Standardization and documentation of Varicocele evaluation.
Current opinion in urology, 2011Co-Authors: Peter J. Stahl, Peter N SchlegelAbstract:Purpose of review Our present understanding of the clinical impact of Varicocele on male fertility and the efficacy of Varicocele treatment is limited by the absence of an objective, reproducible, and standardized diagnostic evaluation. Herein we review the clinical evaluation of Varicocele. The prognostic relevance of Varicocele grade and venous diameter measured with ultrasound is explored. Recent findings A directed history, physical examination of the warmed scrotum, and results of one or multiple semen analyses must be documented in all men with Varicoceles. Color Doppler ultrasonography is indicated in cases when the physical examination is indeterminate. Unfortunately, physical examination is limited by intraobserver and interobserver bias, and standardized criteria for the ultrasonographic diagnosis of Varicocele do not exist. Despite these limitations, both Varicocele grade and venous diameter measured on ultrasound are prognostically useful parameters. In select cases, measurement of serum testosterone and assessment of sperm DNA integrity may also be clinically helpful. Summary The absence of standardized, reproducible clinical, and radiographic evaluations for Varicocele has contributed substantially to our present difficulties in selecting patients who are likely to benefit from Varicocele treatment and in counseling affected men. Consensus regarding the optimal evaluation of Varicoceles and widespread acceptance of a standardized evaluation is necessary.
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role of Varicocelectomy in men with nonobstructive azoospermia
Fertility and Sterility, 2004Co-Authors: Peter N Schlegel, Jeremy KaufmannAbstract:Abstract Objective To evaluate the benefits of Varicocelectomy in men with nonobstructive azoospermia. Design Retrospective review of effect of prior Varicocelectomy on sperm retrieval rates in men with nonobstructive azoospermia. Chart review of men with nonobstructive azoospermia who underwent microsurgical Varicocelectomy to determine the effect of the procedure on the need for testicular sperm extraction (TESE). Setting Tertiary, university-based referral center. Patient(s) Men with clinical Varicoceles and nonobstructive azoospermia. Intervention(s) Microsurgical Varicocelectomy, TESE. Main outcome measure(s) Return of sperm to the ejaculate and need for TESE after Varicocele repair, ability to find sperm using microdissection TESE. Result(s) Of 31 men who underwent Varicocele repair at one institution for documented nonobstructive azoospermia, 7/31 (22%) had sperm reported on at least one semen analysis postoperatively. However, only 3/31 (9.6%) men after Varicocele repair had adequate motile sperm in the ejaculate for ICSI, without TESE. Sperm retrieval rates for men with Varicoceles were not affected by a history of prior Varicocelectomy. Conclusion(s) Men with clinical Varicoceles that are associated with nonobstructive azoospermia will rarely have adequate sperm in the ejaculate after Varicocele repair to avoid TESE. A history of prior Varicocele repair does not appear to affect the chance of sperm retrieval by TESE for men with clinical Varicoceles and nonobstructive azoospermia. The benefits of Varicocelectomy in men with nonobstructive azoospermia may be less than previously reported.
