Outcome of assisted reproductive technology in met with treated and untreated varicocele, systematic review and meta-analysis

Varicocele affects approximately 35%-40% of men presenting for an infertility evaluation. There is fair evidence indicating that surgical repair of clinical varicocele improves semen parameters, decreases seminal oxidative stress and sperm DNA fragmentation, and increases the chances of natural conception. However, it is unclear whether performing varicocelectomy in men with clinical varicocele prior to assisted reproductive technology （ART） improve treatment outcomes. The objective of this study was to evaluate the role of varicocelectomy on ART pregnancy outcomes in nonazoospermic infertile men with clinical varicocele. An electronic search was performed to collect all evidence that fitted our eligibility criteria using the MEDLINE and EMBASE databases until April 2015. Four retrospective studies were included, all of which involved intracytoplasmic sperm injection （ICSI）, and accounted for 870 cycles （438 subjected to ICSI with prior varicocelectomy, and 432 without prior varicocelectomy）. There was a significant increase in the clinical pregnancy rates （OR = 1.59, 95% CI. 1.19-2.12, 12 = 25%） and live birth rates （OR = 2.17, 95% CI： 1,55-3.06, I^2 = 0%） in the varicocelectomy group compared to the group subjected to ICSI without previous varicocelectomy. Our results indicate that performing varicocelectomy in patients with clinical varicocele prior to ICSI is associated with improved pregnancy outcomes.

Critical evaluation of two models of flow cytometers for the assessment of sperm DNA fragmentation:an appeal for performance verification

Lack of standardized,reproducible protocols and referencO values is among the challenges faced when using new or upgraded versions of instruments in reproductive laboratories and flow cytometry.Terminal deoxynucleotidyl transferase dUTP nick end labeling(TUNEL)assay combined with flow cytometry routinely used for diagnostic measurement of sperm DNA fragmentation(SDF)is a unique example.Any change in the setting of the standard instrument,including upgrades of hardware or software,can lead to different results and may affect clinicians'decision for treatment.Therefore,we compared TUNEL results of SDF obtained from a standard(C6)flow cytometer with a newer version of the same instrument(C6 Plus)and examined the cutoff,sensitivity,and specificity without calibration(adjustment)and after adjustment.Identical sperm preparation and matched acquisition settings were used to examine the performance of two flow cytometers.The strength of agreement of the results between the two observers was also assessed.After adjustment of the settings,overall concordance became high and the two cytometers showed 100%positive and negative predictive value with 100%area under the curve.The overall correlation coefficient observed between C6 and C6 Plus was highly significant(P<0.0001;r=0.992;95%confidence interval[Cl]:0.982-0.997).After adjustment,the two cytometers showed very high precisi on of 98%and accuracy of>99%.The in terobserver agreeme nt on C6 flow cytometer for the two observers was 0.801±0.062 and 0.746±0.044 for C6 Plus.We demonstrated a strong agreement between the samples tested on the two flow cytometers after calibration and established the robustness of both instruments.

Multi-center evaluation of oxidation-reduction potential by the MiOXSYS in males with abnormal semen

According to the World Health Organization(WHO),oxidative stress(OS)is a significant contributor to male infertility.SeminalOS can be measured by a number of assays,all of which are either costly or time sensitive and/or require large semen volume andcomplex instrumentation.One less expensive alternative is to quantify the oxidation-reduction potential(ORP)with the MiOXSYS.In this international multi-center study,we assessed whether ORP levels measured by the MiOXSYS could distinguish semensamples that fall within the 2010 WHO normal reference values from those that do not.Semen samples were collected from 2092patients in 9 countries;ORP was normalized to sperm concentration(mV/10^6 sperm/ml).Only those samples with a concentration>1×10^6 sperm ml1 were in eluded.The results showed that 199 samples fell within the WHO no rmal refere nee range while theremaining 1893 samples did not meet one or more of the criteria.ORP was negatively correlated with all semen parameters(P <0.01)except volume.The area under the curve for ORP was 0.765.The ORP cut-off value(1.34 mV/10^6 sperm/ml)was able todifferentiate specimens with abnormal semen parameters with 98.1%sensitivity,40.6%specificity,94.7%positive predictivevalue(PPV)and 66.6%negative predictive value(NPV).When used as an adjunct to traditional semen analysis,ORP levels mayhelp identify altered functional status of spermatozoa caused by OS in cases of idiopathic male infertility and in male partners ofcouples sufferi ng recurre nt pregna ncy loss,and thereby directi ng these men to relevant medical therapies and lifestyle modificati ons.

The new 6^(th) edition of the WHO Laboratory Manualfor the Examination and Processing of HumanSemen: is it a step toward better standard operatingprocedure?

Semen analysis(SA)remains the cornerstone of male infertility evaluation and should ideally be performed by an accredited andrology laboratory or in vitro fertilization(IVF)clinics based on the standards defined by the World Health Organization(WHO)for the Examination and Processing of Human Semen and in accordance with the International Organization for Standardization’s Basic Semen Examination on Specification and Test Methods.

Novel insights into the pathophysiology of varicocele and its association with reactive oxygen species and sperm DNA fragmentation

Varicocele has been associated with reduced male reproductive potential. With the advances in biomolecular techniques, it has been possible to better understand the mechanisms involved in testicular damage provoked by varicocele. Current evidence suggests the central role of reactive oxygen species （ROS） and the resultant oxidative stress （OS） in the pathogenesis of varicocele-associated male subfertility although the mechanisms have not yet been fully described and it is likely to be multifactorial. Excessive ROS is associated with sperm DNA fragmentation, which may mediate the clinical manifestation of poor sperm function and fertilization outcome related to varicocele. Testing of ROS/OS and DNA fragmentation has the potential to provide additional diagnostic and prognostic information compared to conventional semen analysis and may guide therapeutic management strategies in individual patient.

Outcome of varicocele repair in men with nonobstructive azoospermia： systematic review and meta-analysis

The objective of this systemic review was to evaluate the benefit of repairing clinical varicocele in infertile men with nonobstructive azoospermia （NOA）. The surgically obtained sperm retrieval rate （SRR） and pregnancy rates following assisted reproductive technology （ART） with the use of retrieved testicular sperm were the primary outcomes. The secondary outcomes included the presence of viable sperm in postoperative ejaculate to avoid the testicular sperm retrieval and pregnancy rates （both assisted and unassisted） using postoperative ejaculated sperm. An electronic search to collect the data was performed using the MEDLINE and EMBASE databases until April 2015. Eighteen studies were included in this systematic review and accounted for 468 patients who were diagnosed with NOA and varicocele. These patients were subjected to either surgical varicocele repair or percutaneous embolization. Three controlled studies evaluating sperm retrieval outcomes indicated that in patients who underwent varicocelectomy, SRR increased compared to those without varicocele repair （OR： 2,65; 95% Cl. 1.69-4.14; P 〈 0.001）. Although pregnancy rates with the use of testicular sperm favored the varicocelectomy group, results were not statistically significant （clinical pregnancy rate OR： 2.07; 95% CI： 0.92-4.65; P = 0.08; live birth rate OR： 2.19; 95% CI： 0.99-4.83; P = 0.05）. The remaining fifteen studies reported postoperative semen analysis results. In 43.9% of the patients （range： 20.8%-55.0%）, sperm were found in postoperative ejaculates. Pregnancy rates for unassisted and assisted （after IVF/ICSI） were 13.6% and 18.9% in the group of men with sperm in postoperative ejaculates, respectively. Our findings indicate that varicocelectomy in patients with NOA and clinical varicocele is associated with improved SRR. In addition, approximately 44% of the treated men will have enough sperm in the ejaculate to avoid sperm retrieval. Limited data on pregnancy outcomes with both postoperative ejaculated sperm and harvested testicular sperm preclude any firm conclusion with regard to the possible increased fertility potential in treated individuals. In conclusion, the results of our study indicate that infertile men with NOA and clinical varicocele benefit from varicocelectomy. Given the low/moderate quality of evidence available, it is advisable that doctors discuss with their patients with NOA the risks and benefits of varicocele repair.

Effect of varicocele on semen characteristics according to the new 2010 World Health Organization criteria： a systematic review and meta-analysis

This study investigated the effects of varicocele on semen parameters in infertile men based on the new 2010 World Health Organization laboratory manual for the examination of human semen. Semen analysis results （volume, sperm count, motility, and morphology） were the primary outcomes. An electronic search to collect the data was conducted using the Medline/PubMed, SJU discover, and Google Scholar databases. We searched articles published from 2010 to August 2015, i.e., after the publication of the 2010 WHO manual. We included only those studies that reported the actual semen parameters of adult infertile men diagnosed with clinical varicocele and contained a control group of either fertile men or normozoospermic men who were not diagnosed with varicocele. Ten studies were included in the meta-analysis, involving 1232 men. Varicocele was associated with reduced sperm count （mean difference： -44.48 x 106 ml-1; 95% Ch -61.45, -27.51 x 106 ml-1; P〈 0.001）, motility （mean difference： -26.67%; 95% Ch -34.27, -19.08; P 〈 0.001）, and morphology （mean difference： -19.68%; 95% Ch -29.28, -10.07; P 〈 0.001） but not semen volume （mean difference： -0.23 ml; 95% CI： -0.64, 0.17）. Subgroup analyses indicated that the magnitude of effect was influenced by control subtype but not WHO laboratory manual edition used for semen assessment. We conclude that varicocele is a significant risk factor that negatively affects semen quality, but the observed pooled effect size on semen parameters does not seem to be affected by the WHO laboratory manual edition. Given most of the studies published after 2010 still utilized the 1999 manual for semen analysis, further research is required to fully understand the clinical implication of the 2010 WHO laboratory manual on the association between varicocele and semen parameters.

Proteomic signatures of infertile men with clinical varicocele and their validation studies reveal mitochondrial dysfunction leading to infertility

To study the major differences in the distribution of spermatozoa proteins in infertile men with varicocele by comparative proteomics and validation of their level of expression. The study-specific estimates for each varicocele outcome were combined to identify the proteins involved in varicocele-associated infertility in men irrespective of stage and laterality of their clinical varicocele. Expression levels of 5 key proteins （PKARIA, AK7, CCT6B, HSPA2, and ODF2） involved in stress response and sperm function including molecular chaperones were validated by Western blotting. Ninety-nine proteins were differentially expressed in the varicocele Eroup. Over 87% of the DEP involved in major energy metabolism and key sperm functions were underexpressed in the varicocele group. Key protein functions affected in the varicocele group were spermatogenesis, sperm motility, and mitochondrial dysfunction, which were further validated by Western blotting, corroborating the proteomics analysis. Varicocele is essentially a state of energy deprivation, hypoxia, and hyperthermia due to impaired blood supply, which is corroborated by down-regulation of lipid metabolism, mitochondrial electron transport chain, and Krebs cycle enzymes. To corroborate the proteomic analysis, expression of the 5 identified proteins of interest was validated by Western blotting. This study contributes toward establishing a biomarker ＂fingerprint＂ to assess sperm quality on the basis of molecular parameters.

Specialized sperm function tests in varicocele ant Ihe future of andrology laboratory

Varicocele is a common medical condition entangled with many controversies. Though it is highly prevalent in men with infertility, still it marks its presence in males who do have normal fertility. Determining which patients are negatively affected by varicocele would enable clinicians to better select those men who benefitted the most from surgery. Since conventional semen analysis has been limited in its ability to evaluate the negative effects of varicocele on fertility, a multitude of specialized laboratory tests have emerged. In this review, we examine the role and significance of specialized sperm function tests with regards to varicocele. Among the various tests, analysis of sperm DNA fragmentation and measurements of oxidative stress markers provide an independent measure of fertility in men with varicocele. These diagnostic modalities have both diagnostic and prognostic information complementary to, but distinct from conventional sperm parameters. Test results can guide management and aid in monitoring intervention outcomes. Proteomics, metabolomics, and genomics are areas; though still developing, holding promise to revolutionize our understanding of reproductive physiology, including varicocele.

Bibliometrics： tracking research impact by selecting Lhe appropriate metrics

Traditionally, the success of a researcher is assessed by the number of publications he or she publishes in peer-reviewed, indexed, high impact journals. This essential yardstick, often referred to as the impact of a specific researcher, is assessed through the use of various metrics. While researchers may be acquainted with such matrices, many do not know how to use them to enhance their careers. In addition to these metrics, a number of other factors should be taken into consideration to objectively evaluate a scientist＇s profile as a researcher and academician. Moreover, each metric has its own limitations that need to be considered when selecting an appropriate metric for evaluation. This paper provides a broad overview of the wide array of metrics currently in use in academia and research. Popular metrics are discussed and defined, including traditional metrics and article-level metrics, some of which are applied to researchers for a greater understanding of a particular concept, including varicocete that is the thematic area of this Special Issue of Asian Journal of Andrology. We recommend the combined use of quantitative and qualitative evaluation using judiciously selected metrics for a more objective assessment of scholarly output and research impact.

Reduced semen quality in patients with testicular cancer seminoma is associated with alterations in the expression of sperm proteins

Testicular cancer seminoma is one of the most common types of cancer among men of reproductive age.Patients with this condition usually present reduced semen quality,even before initiating cancer therapy.However,the underlying mechanisms by which testicular cancer seminoma affects male fertility are largely unknown.The aim of this study was to investigate alterations in the sperm proteome of men with seminoma undergoing sperm banking before starting cancer therapy,in comparison to healthy proven fertile men(control group).A routine semen analysis was conducted before cryopreservation of the samples(n=15 per group).Men with seminoma showed a decrease in sperm motility(P=0.019),total motile count(P=0.001),concentration(P=0.003),and total sperm count(P=0.001).Quantitative proteomic analysis identified 393 differentially expressed proteins between the study groups.Ten proteins involved in spermatogenesis,sperm function,binding of sperm to the oocyte,and fertilization were selected for validation by western blot.We confirmed the underexpression of heat shock-related 70 kDa protein 2(P=0.041),ubiquinol-cytochrome C reductase core protein 2(P=0.026),and testis-specific sodium/potassium-transporting ATPase subunit alpha-4(P=0.016),as well as the overexpression of angiotensin I converting enzyme(P=0.005)in the seminoma group.The altered expression levels of these proteins are associated with spermatogenesis dysfunction,reduced sperm kinematics and motility,failure in capacitation and fertilization.The findings of this study may explain the decrease in the fertilizing ability of men with seminoma before starting cancer therapy.

Proteomic analysis of seminal plasma from bilateral varicocele patients indicates an oxidative state and increased inflammatory response

Seminal plasma is a rich source of proteins and serves as an ideal sample for proteomic analysis of male infertility.In varicoceleassociated in fertility,the contributory role of semi nal plasma proteins specific to un ilateral and bilateral varicocele is not clear.Furthermore,there is a lack of specific protein biomarker to differentiate bilateral from unilateral varicocele.The main objective is to identify the differentially regulated molecular and cellular pathways in bilateral varicocele?Furthermore,we intend to identify seminal plasma biomarkers to differentiate bilateral and unilateral varicocele patients in comparison with fertile healthy men.Global proteomic an alysis of seminal plasma protei ns has identified the function ality of d iff ere ntially expressed proteins(DEPs)in varicocele patients.Bioinformatic analysis has revealed response to reactive oxygen species and oxidative stress,and tissue homeostasis as top process pathways that are affected in bilateral varicocele patients compared to fertile healthy men.In comparison with unilateral varicocele patients,inflammatory response pathways were dysregulated,especially interleukin 6(IL-6)signaling and Janus kinasesignal transducer and activator of transcription(Jak?STAT)pathways,in bilateral varicocele patients,owing to the involvement of underexpressed DEPs.Key DEPs associated with oxidative stress(peroxiredoxin 2;PRDX2),DNA fragmentation(fatty acid synthase;FASN),and inflammatory resp onse(fibr on ectin 1;FN1)validated by western blot analysis revealed differential expressi on of these proteins in unilateral and bilateral varicocele groups.Altered expression of DEPs and its association with key processes show that the seminal plasma homeostasis is compromised in bilateral varicocele patients?Furthermore,we propose PRDX2,FASN,and FN1 as potential noninvasive seminal plasma markers for the differentiation of unilateral and bilateral varicocele patients.

Proteomic analysis of mature and immature ejaculated spermatozoa from fertile men

Dysfunctional spermatozoa maturation is the main reason for the decrease in sperm motility and morphology in infertile men. Ejaculated spermatozoa from healthy fertile men were separated into four fractions using three-layer density gradient. Proteins were extracted and bands were digested on a LTQ-Orbitrap Elite hybrid mass spectrometer system. Functional annotations of proteins were obtained using bioinformatics tools and pathway databases. Western blotting was performed to verify the expression levels of the proteins of interest. 1469 proteins were identified in four fractions of spermatozoa. The number of detected proteins decreased according to the maturation level of spermatozoa. During spermatozoa maturation, proteins involved in gamete generation, cell motility, energy metabolism and oxidative phosphorylation processes showed increasing expression levels and those involved in protein biosynthesis, protein transport, protein ubiquitination, and response to oxidative stress processes showed decreasing expression levels. We validated four proteins （HSP 70 1A, clusterin, tektin 2 and tektin 3） by Western blotting. The study shows protein markers that may provide insight into the ejaculated spermatozoa proteins in different stages of sperm maturation that may be altered or modified in infertile men.

Varicocele and male infertility： current concepts and Future perspectives

Andrology 的亚洲杂志的这期特刊充分被奉献给精索静脉曲张的题目的区域，它是泌尿学， Andrology，和繁殖的药的地里的最争论的期之一。作为一个临床的实体认出了为在一个世纪，从拉丁文的精索静脉曲张：静脉曲张(扩大静脉) 并且从希腊语：kele (肿瘤) 仍然在男富饶和 gonadal 功能上在可争辩的否定效果上在科学家和临床医生之中得到激烈的争论并且自从它的第一在 18 th 世纪。

Afterword to varicocele and male infertility： curreni concepts and future perspectives

我们总结并且评论贡献者讨论到 Andrology 的亚洲杂志的这期特刊的话题。精索静脉曲张的范围盖住一个宽系列，包括 proteomics 和 metabolomics，神经质的控制， interventional 治疗，和帮助繁殖技术(艺术) 。话题的选择证明这个题目的区域和机会研究的令人激动的宽度为两个都增加理解并且与精索静脉曲张改进男性的繁殖健康成立。

Proteomic analysis reveals dysregulated cell sign aling in ejaculated spermatozoa from in fertile men

Dysfunctional sperm maturation is the primary reason for the poor sperm motility and morphology in infertile men.Spermatozoa from infertile men were fractioned on three-layer density gradient(80%,60%,and 40%).Fraction 1(Fl)refers to the least mature stage having the lowest den sity,whereas the fraction 4(F4)in eludes the most dense and morphologically mature motile spermatozoa.Fraction 2(F2)and fraction 3(F3)represent the intermediate stages.Proteins were extracted and separated by dimensional gel.Bands were digested with trypsin and analyzed on a LTQ-Orbitrap Elite hybrid mass spectrometer system.Functional annotations of proteins were obtained using bioinformatics tools and pathway databases.A total of 1585 proteins were detected in the four fractions of spermatozoa.A dysregulated protein turnover and protein folding may lead to accumulation of defective proteins or proteins that otherwise would have been eliminated during the process of maturation,resulting in the impairment of sperm fun ction.Aberra nt chaper one expressi on may be a major con tributing factor to the defective sperm function.Androge n receptor was predicted as a transcription regulator in one of the networks and the affected pathways were chaperone-mediated stress response,proteosomal pathway,and sperm function.The down regulation of key pathways and protei ns which compromises the fertilizi ng potential of spermatozoa may provide in sight into the mecha nisms that lead to male infertility.