Faculty of Medicine, Tanta University, Tanta, Egypt.
Mansoura University Urology and Nephrology Center, Mansoura, Egypt.
Andrology. 2019 Mar;7(2):193-198. doi: 10.1111/andr.12580. Epub 2019 Jan 7.
There is wide agreement nowadays that a clinical varicocoele should be ligated to treat male factor infertility. However, the significance of testicular artery preservation in patients with severe oligozoospermia has not been addressed before.
To assess the outcome of varicocelectomy in infertile men with severe oligozoospermia and clinical varicocoeles and to compare internal spermatic artery preservation vs. artery ligation.
This prospective randomized study included 302 infertile patients with severe oligozoospermia and clinical (grade II/III) varicocoeles. Patients were randomized into two groups: group A (150 patients) underwent artery-preserving varicocelectomy (APV) and group B (152 patients) underwent artery-ligating varicocelectomy (ALV). The primary outcome was to assess the changes in sperm density and motility at 3 and 6 months postoperatively in both groups. The secondary outcome was to compare the natural pregnancy rate at 1-year of follow-up. Univariate and multivariate analyses were performed to determine factors affecting pregnancy rate.
In both groups, there was a statistically significant improvement in sperm density and motility at 3 and 6 months postoperatively. In group A, there was a greater improvement in sperm density (p < 0.001) and motility (p < 0.001) compared to group B. At 1-year follow-up, overall 35.1% achieved a natural pregnancy. Group A achieved a significantly higher natural pregnancy rate (40% vs. 30%, p value = 0.03) compared to group B. Smaller testicular volume and ALV were the independent predictors of lower pregnancy rate ((HR = 3.2, 95% CI 1.2-8.3, p = 0.01) and (HR = 3.2, 95% CI 1.4-7.1, p = 0.003), respectively).
In men with severe oligozoospermia and a clinical varicocoele, APV results in improved outcomes as compared to ALV with respect to semen parameters and natural pregnancy rates. Therefore, all attempts should be made to preserve internal spermatic arteries (ISA) during varicocelectomy in men with severe oligozoospermia.
现今，人们广泛认同临床精索静脉曲张应该通过结扎来治疗男性不育症。然而，对于严重少精子症患者，保留睾丸内动脉的意义尚未得到明确。
评估严重少精子症合并临床精索静脉曲张患者行精索静脉曲张手术后的结果，并比较保留睾丸内动脉与结扎睾丸内动脉的效果。
本前瞻性随机研究纳入了 302 例严重少精子症合并临床（Ⅱ/Ⅲ级）精索静脉曲张的不育患者。患者被随机分为两组：A 组（150 例）行保留睾丸内动脉的精索静脉曲张结扎术（APV），B 组（152 例）行结扎睾丸内动脉的精索静脉曲张结扎术（ALV）。主要结局是评估两组患者术后 3 个月和 6 个月时精子密度和活力的变化。次要结局是比较 1 年随访时的自然妊娠率。采用单因素和多因素分析确定影响妊娠率的因素。
两组患者术后 3 个月和 6 个月时精子密度和活力均有统计学意义的改善。A 组精子密度（p<0.001）和活力（p<0.001）的改善程度明显优于 B 组。1 年随访时，总共有 35.1%的患者自然妊娠。A 组的自然妊娠率显著高于 B 组（40%比 30%，p 值=0.03）。较小的睾丸体积和 ALV 是较低妊娠率的独立预测因素（HR=3.2，95%CI 1.2-8.3，p=0.01 和 HR=3.2，95%CI 1.4-7.1，p=0.003）。
对于严重少精子症合并临床精索静脉曲张的患者，APV 与 ALV 相比，在精液参数和自然妊娠率方面均有更好的结果。因此，在严重少精子症患者行精索静脉曲张手术时，应尽量保留睾丸内动脉。
