VARICOCELE AND HYPOGONADISM AMONG ADULTS: A PROSPECTIVE STUDY AMONG INFERTILE MEN IN TAMALE, GHANA

Abstract

Varicocele is a disorder of venous return caused by abnormal enlargement of pampiniform plexus draining the testicles. This condition is common among men seeking medical attention for fertility problems, sexual dysfunction or complains of continuous scrotal discomfort. Varicocele repair has been recommended for varicose patients with such complaints, however, the effect of microsurgical sub-inguinal varicocelectomy on semen parameters, gonadotropins or factors to predict which of the patients are most likely to benefit from the surgery has not been determined in Ghana, hence the aim of this study. This was an interventional study conducted at the Urology Unit of the Tamale Teaching Hospital, Tamale, Ghana between September 2017 to August 2021. Participants included in the study were randomised into surgery group and observed group and were aged between 36 – 69 years old. Duplicate semen samples (mean values adopted) were collected at the onset, after 6-,9- and 12 months, and assessed following the criteria as established by World Health Organization (WHO). Blood samples were collected and serum total testosterone, follicle stimulating hormones (FSH), luteinizing hormone (LH) were assayed at onset (baseline), 12- ,24-, 36-, and 48-months intervals (4 years follow-up). Testicular hemodynamics (peak systolic velocity, end-diastolic velocity and resistive index) were measured using color duplex Doppler ultrasonography (CDUS) at each interval and recorded. Varicocelectomy was performed for the surgery group and no intervention was given to the observed group after baseline measurements. The data was computed using GraphPad Prism (v8.0) at an alpha of 0.05. Paper I involved the effect of the varicocelectomy on semen parameters after 180 days. It was found that long-standing varicocele may affect semen parameters and this may be seen by causing a further decrease in semen volume, total sperm count, concentration of spermatozoa, motility, or normal sperm morphology. Paper II involved the hricocelectomy on gonadotropins after 48 months follow-up. The study found that varicocele may cause Leydig cell damage and this may be seen by causing a further decrease in total testosterone and a concomitant rise in follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Again, it was observed that serum total testosterone, FSH, and LH observed spike changes within the first- and second-year in the surgery group but changes were marginal from the third year onwards (Paper II). Paper III found that the significant predictive factors associated with improved semen characteristics following microsurgical sub-inguinal varicocelectomy in infertile men were; pre-operative low serum FSH, high testosterone, and low left capsular resistive index (L_RIcap). In varicocele patients, blood supply to the testicular tissues is significantly reduced evidenced by the increase in a resistive index (RI) in capsular arteries of the observed group and this appears to improve after surgery as observed by a reduced RI_cap in the surgery group (Paper IV). Given the predictive factors associated with improved semen parameters in patients with varicocele, it is worth recognizing that improvement on the semen quality post varicocele repair does not guarantee patients to father children. Further studies on a larger population of varicocele patients with pregnancy rate as the primary outcome will help to conclusively determine the effectiveness of microsurgical sub-inguinal varicocelectomy. Also, varicocelectomy plus supraphysiologic dosages of human chorionic gonadotropin (hCG) therapy have found significant superiority in infertile men with varicocele and could be a topic of further studies.