Abstract
Study question
Which treatment option is better in men with clinical varicocele and pathozoospermia: laparoscopic, microsurgical varicocelectomy, or antioxidant (nutrient) therapy alone?
Summary answer
Microsurgical varicocelectomy and laparoscopy are more effective in pathozoospermia treatment than observation and nutrient therapy alone. Simultaneously, there are no differences between these surgical methods.
What is known already
It is known that varicocele may cause testicular dysfunction and infertility due to increased oxidative stress and sperm DNA damage. In recent meta-analyses comparing surgery versus follow-up in men with clinical varicocele and pathozoospermia, semen quality was better in the surgery group. However, it is unclear why varicocelectomy leads to sperm quality improvement only in 60–70% of cases, and real fertility in 30–40% of couples. The microsurgical technique leads to fewer complications compared with others, but there are no powerful RCTs to compare various techniques’ efficacy. Simultaneously, the use of antioxidants may give a similar increase in pregnancy rates.
Study design, size, duration
This retrospective case-control study recruited 218 men from infertile couples with clinical varicocele and pathozoospermia who underwent microsurgical, laparoscopic varicocelectomy and antioxidant therapy alone at clinics of Moscow from January 2010 to December 2019.
Participants/materials, setting, methods
Clinical, laboratory data of patients in the groups: A) the observation group (n = 33), B) the group treated with nutrients alone (n = 63), C) the group of patients after microsurgical varicocelectomy (n = 86), and D) the group of patients who underwent laparoscopy (n = 36), were obtained. The sperm was evaluated according to WHO–2010, DNA fragmentation by chromatin dispersion in an agarose gel. We calculated standardized effect (Es) to determine study power.
Main results and the role of chance
After 3 months, varicocelectomy led to an increase in sperm concentration and motility: the median of the total progressively motile sperm count (TPMSC) increase in the group A was +0.4 million; B - +1.9 million; C - +17.1 million (p < 0.05); D - +21.2 million (p < 0.05). A clinically significant increase in this indicator after varicocelectomy was found in 2/3 of cases: 65% (С; p < 0.05) and 67% (D; p < 0.05) with 38% (A) and 42% (B). Varicocelectomy led to a decrease in sperm DNA fragmentation by an average of 5.5% (p < 0.05) with an improvement in 59% of patients. Simultaneously, a 3-month therapy with nutrients similarly decreased DNA fragmentation: 5.5% (p < 0.05), 66% of improvement cases. The differences in surgery efficacy between C and D were insignificant (p > 0.05). The laparoscopic surgery demonstrated higher standardized effect (Es) than microsurgical operation (Es = 0.70 and 0.44, with 0.29 in the patients receiving nutrients and 0.22 in the patients of the control group).
Limitations, reasons for caution
The main limitations were: 1) different sample (group) sizes and 2) insufficient power of the performed study (Es < 0.8), which does not allow us to exclude a type II error – unreasonable rejection of differences.
Wider implications of the findings: In selected patients with varicocele and pathozoospermia, antioxidant therapy can be used as a monotherapy or as adjuvant therapy.
Trial registration number
Not applicable
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