Elif ÖZER, Demokan EROL, Ayhan KARABULUT, Levent EMİR, Refik AYGIN

Incidence of accidental spermatic artery ligation during inguinal varicocelectomy with sedoanalgesia and its effects on sperm concentration

Amaç: Bu çalışma lokal anestezi ile yapılan varikoselektomi sırasında ne sıklıkla testiküler arterin aksi dental olarak yaralandığım saptamak ve arter korunması ile bağlanmasının semen parametreleri ve özellikle strict sperm morfolojisi üzerine etkisini karşılaştırmak için dizayn edilmiştir. Gereç ve Yöntem: Varikosel tanısı alan 44 infertil hasta bu çalışmaya dahil edildi. Semen analizleri ve testiküler volüm ölçümleri postoperafif en az 3 ay sonra tekrar edildi. Arter bağlanan ve korunan gruplardaki seminal parametre değişiklikleri analiz edildi. Bulgular: Spermatik arter yaralanması 44 hastanın 19'unda (43.1 %) belirlendi. Olguların tümünde, preoperatif sperm konsantrasyonu ortalama 41±28 10>/ml'dan 53 ± 23 10/ml'ye (p< 0.05),ileri hareketli (+4 ve +3 motilite) sperm oranı 51 ± 16'dan 57 ± 12'ye (p0.05) değişiklik gösterdi. Arter bağlanan grupta,varikoselektomi sonrası sperm konsantrasyonunda istatistiki olarak anlamlı farklılık gözlenirken arter korunan grupta hem sayı hem de motilitede belirgin düzelme gözlendi (p0.05). Testis volüm ölçümleri postoperatif dönemde iki grupta da belirgin değişiklik göstermedi (p>0.05). İki grup arasında gözlenen tek fark arter korunan grupta sperm motiltesindeki iyileşmedir. Sonuç: Düşük gradeli varikosellerde varikoselektomi morfolojiyi dûzeltmemektedir.

Sedoanaljezi altında yapılan inguinal varikoselektomi sırasındaki aksidental spermatik arter bağlanma sıklığı ve bunun sperm konsantrasyonu, motilitesi ve kruger morfolojisi üzerine etkileri

Purpose: This study was designed to determine how often the testicular artery is accidentally ligated during varicocelectomy with local anaesthesia and to compare the impact of artery ligation and preservation on seminal parameters, particularly strict sperm mophology. Method: 44 infertile patients with the diagnosis of varicocele were enrolled into the study. Semen analyses and testicular volume measurements were repeated after a minumum period of three months postoperatively. The change in seminal parameters after the operation was analysed in artery- ligated and preserved groups. Results: Spermatic artery injury was determined in 19 (43.1 %) out of 44 patients. In overall patients, preoperative sperm cencentration increased from an average of41± 2810°/ml to 53 ± 23 10/ml (p< 0.05), forward motility (+4 plus +5 motility) increased from 51 ± 16 to 57 ± 12 (p0.05). In the artery ligated group, a statistically significant difference was recorded in sperm concentration after varicocelectomy whereas both sperm concentration and motility improved significantly in the artery preserved group (p0.05). Testicular volumes did not reveal significant change in any groups postoperatively (p>0.05). The only difference observed between the two groups was the improvement in sperm motility in the artery-preserved group. Conclusion: Varicocelectomy in low grade varicoceles does not improve strict sperm morphology.

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1. Albert M, Gallo JM, Escailer D, Parseghian N, Schrevel J, David G. Unexplained in-vitro fertilization failure: implication of acrosomes with a small reacting region revealed by monoclonal antibody. Hum Reprod 1992; 7: 1249-1256.
2. Bielsa MA, Andolz P, Gris JM, Martinez P, Egozcue J. Which semen parameters have a predictive value for pregnancy in infertile couples? Human Reprod 1994; 9:1 887- 1890.
3. Schatte EC, Hırshberg SJ, Fallick ML, Lipshultz LI, Kim ED. Varicocelectomy improves sperm strict morphology and motility J Urol 1998; 160: 1338-1340.
4. Seftel AD, Rutchik SD, Chen H, Stovsky M, Goldfarb J, Desai N. Effects of subinguinal varicocele ligation on sperm concentration, motility and Kruger morphology. J Urol 1997; 158: 1800-1803.
5. Rowe PJ, Comhaire FH, Hargreave TB, Mellows HJ. WHO manual for the standardized investigation and diagnosis of the infertile couple. Cambridge: Cambridge University Press, 1993.
6. Aitken RJ, Best FSM, Warner P, Templeton A. A prospective study of the relationship between semen quality and in cases of unexplained infertility. J Androl 1984; 5: 297-303.
7. Bonde JPE, Ernst E, Jensen TK, Hijollund NHI, Kolstad H, Henriksen TB, Scheike T, Giwercman A, Olsen J, Skakkebaek NE. Relation between semen quality and fertility: a population-based study of 430 first pregnancy planners. Lancet 1998; 352: 1172-1177.
8. Barratt CLR, Tomlinson MJ, Cooke ID. Prognostic significance of computerized motility analysis for in-vivo fertilization. Fertil Steril 1993; 60: 520-525.
9. Kruger TF, Menkveld R, Stander FS, Lombard CJ, Van Der Merwe JP, van Zyl JA, Smith K. Sperm morphologic features as a prognostic factor in in vitro fertilization (IVF). Fertil Steril 1986; 46: 1118- 1123.
10. Kruger TF, Acosta AA, Simmons KF, Swanson RJ, Matta JF, Oehninger S. Predictive value of abnormal sperm morphology in in vitro fertilization. Fertil Steril 1988; 49: 112-117.
11. Ombelet W, Vandeput H, Van de Putte G, Cox A, Janssen M, Jacobs P, Bosmans E, Steeno O, Kruger T. Intrauterine insemination after ovarian stimulation with clomiphene citrate: predictive potential of inseminating motile count and sperm morphology. Hum Reprod 1997; 12: 1458- 1462.
12. Karabinus DS, Gelety TJ. The impact of sperm morphology evaluated by strict criteria on intrauterine insemination success. Fertil Steril 1997; 67: 536-541.
13. Lindheim SR, Barad DH, Zinger M, Witt B, Amin H, Cohen B, Fisch H, Barg P. Abnormal sperm morphology is highly predictive of pregnancy outcome during controlled ovarian hyperstimulation and intrauterine insemination. J Assist Reprod Genet 1996; 13: 569-572.
14. Mac Leod J. Seminal cytology in. the presence of varicocele. Fertil Steril 1965; 16 : 735- 738.
15. Schlesinger MH, Wilets IF, Nagler HM. Treatment outcome after varicocelectomy. A critical analysis. Urol Clin N Amer 1994; 21: 517-529.
16. Kamischke A, Nieschlag E. Varicocele treatment in the light of evidence-based andrology. Hum Reprod Update 2001; 7: 65-69.
17. Vasquez-Levin MH, Friedmann P, Goldberg SI, Medley NE, Nagler HM. Response of routine semen analysis and critical assessment of sperm morphology by Kruger classification to therapeutic varicocelectomy. J Urol 1997; 158: 1804-1807.
18. Witt MA, Lipshultz LI. Varicocele, a progressive or static lesion? Urology 1993; 42: 541-543.
19. Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril 1993; 59: 613-616.
20. Jarow JP, Ogle A, Kaspar J, Hopkins M. The testicular artery ramification within the inguinal canal. J Urol 1992; 147: 1290-1292.
21. Mannar JL, Kim Y. Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy rate. J Urol 1994; 152: 1127-1132.
22. Papanikolaou F, Chow V, Jarvi K, Fong B, Ho M, Zini A. Effect of adult microsurgical varicocelectomy on testicular volume. Urology 2000; 56: 136-139.
23. Matsuda T, Horii Y, Yoshida O. Should the testicular artery be preserved at varicocelectomy? J Urol 1993; 149: 1357-1360.
24. Kass EJ, Marcol B. Results of varicocele surgery in adolescents: a comparison of techniques. J Urol 1992; 148: 694-696.
25. Rothman CM, Newmark H, Karson RA. The recurrent varicocele- a poorly recognized problem. Fertil Steril 1981; 35: 552-556.
26. Mastrogiacomo I, Foresta C, Ruzza G, Rizzotti A, Lembo A, Zanchetta R. Pathogenesis of persistent infertility in men after varicocelectomy. Andrologia 1983; 15: 573- 577.
27. Sayfan J, Adam YG, Soffer Y. A new entity in varicocele subfertility: 'the cremasteric reflux'. Fertil Steril; 1980 33: 88-90.
28. Lee LM, Johnson HW, Mc Loughlin MG. Microdissection and radiographic studies of the arterial vasculature of the human testes. J Ped Surg 1984; 19: 297-301.
29. Cayan S, Kadioglu TC, Tefekli A, Kadioglu A, Tellaloglu S. Comparison of results and complications of high ligation surgery and microsurgical high inguinal varicocelectomy in the treatment of varicocele. Urology 2000; 55: 750-754.