Abril - 2017

hould

azoospermic

patients

with

varicocele

disease

undergo

surgery

recover

fertility

ssoc

ras

2017; 63(4):332-335

333

first sperm count was conducted 60 days after surgery, and

subsequently repeated every 60 days.

esults

Of the 25 patients, 10 (40%) presented bilateral varicocele on

physical examination. Left varicocele was identified in nine

(36%) patients, and six (24%) had right-sided varicocele only.

Sperm was found in three (12%) patients treated sur-

gically, four months after the procedure. Six months af-

ter surgery, sperm was identified in five (20%) patients.

After one year of follow-up, only five (20%) patients had

sperm in the ejaculate (Table 1). None of the five patients

presented testicular volume reduction in pre-op. The

concentration of sperm in the patients operated reached

0.5 to 12 million/mL (Vr > 20 million/mL). Out of the

total of 25 patients, three (12%) had changes in karyo-

type, and two (8%) had Y-chromosome microdeletions.

iscussion

The male factor is responsible for about 40% of cases of

marital infertility. A diagnosis of azoospermia is made in

up to 15% of infertile men.

1,2,4,6,7

Non-identification of sperm

in the semen should always be investigated. A differential

diagnosis between obstructive and non-obstructive azoos-

permia is fundamentally important for the treatment and

prognosis of patients.

1,2,4,8

FSH, LH, total testosterone and

estradiol levels combined can demonstrate the testicular

function. Last but not least, measuring the level of fructo-

se in semen offers evidence for obstructive diagnosis.

1,2,4,6,8

Researching the medical history is crucial and can

guide the diagnosis:

1. history of cryptorchidism in childhood and if and

when it was corrected;

2. history of sexually transmitted diseases;

3. previous contact with gonadal-toxic agents or the

use of exogenous androgen, very common in the

absence of sperm;

4. story of retrograde ejaculation (in diabetics, patients

with bladder voiding disorders, changes in patients

undergoing prostatic surgeries) will identify patients

with sperm in post-ejaculation urine analysis.

Karyotype analysis showed 15% of changes in azo-

ospermic patients in the studied group. Regarding

changes in karyotype, Klinefelter syndrome is one of

the most frequent genetic alterations in azoospermic

patients.

1,5-7,12,13

Y-chromosome microdeletions can be

expected in approximately 15 to 20% of patients with

NOA. The Y-chromosome is responsible for determin-

ing the male gender and features three regions known

as AZFa, AZFb, AZFc. That is where the information

for the production and maturation of sperm cells can

be found.

1,5-7,12

This evaluation is truly important be-

cause patients referred for assisted reproduction can

transmit genetic disorders in the absence of genetic

counseling. These patients are unlikely to benefit from

varicocelectomy.

4,6,8,11-13

On physical examination, identification of the vas

deferens is fundamental. The presence of ectopic testicles

or testicles with reduced volumes can be indicative of

testicular failure or poor response to surgical procedure.

These patients have a poorer prognosis.

1,3,4,9

Until recently, the presence of varicocele was not ac-

knowledged in these patients. Varicocele repair should

not be considered in obstructive seminiferous tubules. It

has a prevalence of 15% in the general population and

occurs in 30 to 40% of infertile patients.

1-4

A diagnosis is made during the physical exam with

the patient being brought to a standing position, at room

temperature. Doppler ultrasound can be used as a supple-

mentary method.

1-3

Varicocele is a vascular disease that affects testicular

veins. Its presence causes an inappropriate environment

for the production and development of sperm.

1-4

The

disease can change the concentration, motility, morphol-

ogy and structure of sperm DNA.

1-4

Pathological sperm vein reflux leads to the accumula-

tion of CO

and free radicals, lowering local concentrations

of O

, which affects the functioning of Leydig cells and

Sertoli cells. These cells are responsible for the production

of testosterone and sperm, respectively. The varicocele

can cause atrophy and calcification, hindering cell devel-

opment and espermatogenesis.

1-3,5,6,11-13

TABLE 1

Results of the sperm analysis after varicocelectomy.

Varicocele Cases treated surgically % Sperm positive 4

month Sperm positive 6

month Sperm positive 12

month

Bilateral

3 patients

5 patients

Left

Right

Total

100 12%

20%

Note that even one year after surgery, the rate of sperm recovery was not greater than 20%.