THE EFFECTS OF SUBINGUINAL VARICOCELECTOMY ON KRUGERMORPHOLOGY AND SEMEN PARAMETERS

YUSUF KIBAR, BEDRETTIN SECKIN AND DOGAN ERDURANFrom the Departments of Urology, Sivas Military Hospital, Sivas and Gulhane Military Medical Academy, Ankara, Turkey

ABSTRACT

Purpose: We studied the effect of varicocele ligation on Kruger strict morphology criteria andsemen parameters in patients with infertility.

Materials and Methods: A total of 90 patients diagnosed with varicoceles and a normalmorphological sperm ratio of less than 14% were evaluated before and 6 months after varicoce-lectomy. Preoperatively and postoperatively sperm density, motility and morphology usingKruger strict criteria were analyzed. The Wilcoxon test was used to measure levels of statisticalsignificance in all analyses.

Results: Significant improvement in sperm concentration and motility was evident aftervaricocele ligation (p �0.0002 and �0.0001, respectively). Using the Kruger classification spermmorphology evaluation revealed a significant increase in the percent of normal forms, and offorms with head and acrosome defects (p �0.0001, �0.0014 and �0.0028, respectively). Therewere no concomitant changes in strict morphology in forms with mid piece and tail defects orimmature forms (p �0.05). Of the 90 patients 18 (20%) achieved a successful full-term pregnancy,including 14 via natural cycle intercourse and 4 by intrauterine insemination.

Conclusions: Surgical correction of varicocele was associated with significant improvement indensity, motility and sperm morphology evaluated using the Kruger classification.

KEY WORDS: testis; sperm; varicocele; infertility, male

Varicocele has been considered a reversible cause of malesubfertility for more than 40 years.1 Varicocele is present inapproximately 15% of the general population, in 19% to 41%of men with primary infertility and in 45% to 81% of menwith secondary infertility.2, 3 More recent studies validate theobservations of significant improvements in testicular size,histology, sperm density and motility after varicocelectomy.4The effects of this operation on sperm morphology have beencontroversial, particularly since the criteria for detectingmorphological improvement have not been considered objec-tive.5

Sperm morphology according to Papanicolaou stainingmodified for spermatozoa has been a standard component ofroutine semen analysis according to WHO criteria.6 How-ever, numerous studies suggest that assessing sperm mor-phology using additional criteria may be a significant predic-tor of the fertilization rate in vitro.7 Use of the Kruger strictcriteria to characterize sperm morphology has become thegold standard at many laboratories since its introduction.8, 9

We retrospectively analyzed 90 patients who underwentsemen evaluation in regard to sperm parameters and spermmorphology, which was assessed by Kruger morphologicalcriteria before and after subinguinal varicocelectomy. Sinceexisting data on the effects of varicocelectomy on sperm mor-phology according to Kruger principles is lacking, we per-formed this study to evaluate the effects of subinguinal var-icocelectomy on sperm parameters.

PATIENTS AND METHODS

A total of 90 male partners of couples with a history ofprimary infertility for at least 1 year, varicocele and a normalmorphological sperm ratio of less than 14% were included inthis study at the Gulhane Military Medical Academy hospitalandrology clinic and in vitro fertilization unit betweenSeptember 1997 and June 2001. To exclude female factors a

gynecologist evaluated the female partners. A detailed his-tory and physical examination were performed in all pa-tients. Varicocele diagnosed by physical palpation with thepatient standing with and without the Valsalva maneuverwas confirmed by color Doppler ultrasound. Varicocele sizewas classified as large (grade III), moderate (grade II) andsmall (grade I). Varicoceles were graded subclinical whenpalpation was negative but color Doppler ultrasound waspositive.

When there was no more than a 20% difference in Krugerspermiography results, spermiography was performed atleast twice in separate samples preceding surgery and themean values were calculated to serve as the preoperativevalue. When values differed by more than 20%, a third testwas done.10 Semen analyses were done in the first 6 cases aminimum of 3 months after varicocele repair but semenanalyses and semen samples in these cases were repeated atmonth 6 to ensure standardization. All semen samples wereobtained by masturbation after 3 days of sexual abstinenceand analyzed after liquefaction according to WHO guide-lines.10 Sperm motility and density were determined using aMakler chamber at 20� magnification. Motile and immotilesperm were scored to determine motility using a handcounter. The quality of forward movement of the sperm wasscored in 4 groups, including score a—sperm moving in astraight line with high speed, score b—sperm moving ina reasonably straight line with moderate speed, scorec—sperm moving with a slow, meandering forward progres-sion and score d—sluggish or nonprogressive movement, orno motility.4 While interpreting motility in our study, weincluded preoperative and postoperative differences of scoresa plus b preceding and after the operation.

Sperm morphology was evaluated by examining stainedsmears of 5 to 10 �l. semen. All samples were assessed usingthe Kruger classification. Staining was performed using theDiff Quick staining kit (Baxter Healthcare Corp., Miami,Florida). Briefly, slides were fixed with Diff Quick fixative forAccepted for publication April 26, 2002.

0022-5347/02/1683-1071/0 Vol. 168, 1071–1074, September 2002THE JOURNAL OF UROLOGY® Printed in U.S.A.Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.® DOI: 10.1097/01.ju.0000026956.70079.b6

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15 seconds, stained with Diff Quick solution I for 10 secondsand finally stained with Diff Quick solution II for 5 seconds.Excessive stain is removed immediately by applying distilledwater to the end of the slides. The slides are dried at roomtemperature. Using these criteria spermatozoa are consid-ered normal when the head has a smooth oval configurationwith a well defined acrosome involving 40% to 70% of thesperm head, there are absent neck, mid piece and tail defects,and there are no cytoplasmic droplets of more than half thesize of the sperm head. The length of the sperm head shouldbe 5 to 6 �m. and the diameter should be 2.5 to 3.5 �m. Theclassification is such that borderline normal forms are con-sidered abnormal. All morphological evaluations of Krugerstained slides were performed within 24 hours of sampletechnician collection in blinded fashion. At least 200 sperma-tozoa were evaluated at 1,000� magnification using brightfilled illumination. Evaluation was done by 1 of 2 trainedtechnicians with samples assigned at random. Morphologyevaluation was periodically monitored by 2 technicians usingsets of 3 slides from various donors. The samples were as-signed a code number and evaluated every other week on aregular basis, which was considered an appropriate way ofintroducing routine quality control into the assessment ofsperm morphology. Differences between 10% and 20% inreadings of the same sample were considered acceptable.8, 9

In addition, readings of the same sample by each of the 2technicians were compared and differences no greater than20% were noted.

Modified subinguinal varicocelectomy using spinal anes-thesia with preservation of the spermatic artery and lym-phatic glands was performed in all patients. When present,external venous collaterals were ligated. Under 3.5� loupemagnification the dilated internal spermatic veins were dou-bly ligated with 2-zero silk suture. No attempt was made todeliver the testis. All procedures were performed by sameurologist (Y. K.).

Preoperatively the patients were stratified according tosperm concentration into 3 groups, including group 1—spermconcentration greater than 20 million per ml., group 2—be-tween 5 and 20 million sperm per ml. and group 3—less than5 million sperm per ml. A sperm concentration exceeding 20million per ml., sperm motility 50% or greater with forwardprogression (score a � b) and greater than 14% by the Krugerclassification were considered normal.

Followup assessment was done by chart review and tele-phone. The information included details on patient historyand physical examination, semen parameters and pregnancyoutcome (spontaneous and/or assisted). The mean intervalbetween varicocele repair and mean followup was 18 months(range 12 to 28). Average values of semen parameters in thestudy group are expressed as the mean plus or minus stan-dard error. Differences in sperm density, motility and mor-phology before and after subinguinal varicocelectomy wereevaluated for significance using the nonparametric Wilcoxonsigned rank test.

RESULTS

All men had primary infertility. Mean hospitalization was1.2 day. Mean operative time was 45 minutes in unilateraland 75 minutes in bilateral varicocele cases. The mean age ofthe spouse was 26 � 1.1 years (range 22 to 42). Varicocelewas grades I to III in 16, 24 and 50 cases, respectively. GradeI varicoceles were bilateral in 4 cases and on the left side in12, grade II varicoceles were bilateral in 6 and on the left sidein 18, and grade III varicoceles were on the right side in 4,left side in 36 and bilateral in 10.

Median age and the mean duration of infertility were 26(range 22 to 42) and 3.8 � 1.0 years in the grade I, 27 (range21 to 38) and 4.7 � 1.6 years in the grade II, and 30 (range 22to 36) and 5.1 � 1.1 years in the grade III groups, respec-

tively. Table 1 lists clinical varicocele grades and mean in-fertility times.

Semen volume. Volume was 1 to 6 ml. Preoperative evalu-ation showed 2 cases (2.2%) of abnormally low ejaculatevolume (range 1 to 1.5 ml.) and 1 (1.1%) of high volume (6ml.). Volume in the remaining 87 cases was between 2 and 4ml. These men with low ejaculate volume were excluded fromdata analysis. Preoperative mean semen volume was 2.8 �0.2 ml., which did not significantly differ from the postoper-ative value of 2.6 � 0.3 ml. (p �0.05, table 2).

Sperm concentration. Based on the preoperative concentra-tions 32, 30 and 28 patients were assigned to groups 1 to 3,respectively. All group 1 cases remained in group 1 postop-eratively. Preoperative and postoperative mean sperm con-centration in group A was 42.4 � 3.1 million and 44.1 � 3.5million per ml., respectively. There was no statistical changepostoperatively in patients with a preoperative sperm con-centration of greater than 20 million per ml. (p �0.05). Of the58 patients in groups 2 and 3, 44 (75.8%) improved to groups1 and 2 after varicocelectomy, 23 who began in group 2improved postoperatively to group 1, 5 remained in group 2and 2 dropped to group 3. Eight of the 28 patients who beganin group 3 improved to group 1, 13 improved to group 2 and7 remained in group 3. The preoperative mean sperm con-centration of 22.1 � 4.2 million per ml. (range 6 million to 68million) increased to 38.3 � 6.1 million per ml. at postoper-ative month 6. Using the Wilcoxon signed rank test spermconcentration improved significantly after varicocelectomy(p �0.0002, table 2).

Sperm motility. A total of 68 patients had abnormal spermmotility (score a � b less than 50%, range 0% to 47%). Only22 patients had normal sperm motility preoperatively. Meansperm motility increased from 23.2% � 2.2% to 45.1% � 1.9%at postoperative month 6 (p �0.0001). Postoperative im-provement was noted in 40 of the these 68 patients (58.8%)(table 2). Of the 68 men 20 showed no improvement aftervaricocelectomy, including 12, 6 and 2 with a sperm concen-tration of less than 5 million, between 5 and 20 million, andgreater than 20 million per ml., respectively.

Effects of varicocelectomy on Kruger morphology. Using thenormal morphological sperm ratio of 14% according to theKruger criteria all 90 patients had abnormal preoperativesperm morphology. There were fewer than 4% normal spermforms less in 68 groups 1 and 2 patients, including 36 ingroup 1 with a normal morphological sperm ratio of 0% and32 in group 2 with a ratio of 4% or less. In 22 men in group3 the ratio was between 4% and 14%. The normal morpho-logical sperm level increased from a mean of 2.6% � 0.5% to10.2% � 0.9% at postoperative month 6. Kruger morphologyimproved significantly after varicocele repair (p �0.0001).Forms with head defects decreased from a mean of 55.2% �3.4% to 22.7% � 2.9% (p �0.0014). Forms with acrosomaldefects also decreased from a mean of 16.8% � 1.7% to 8.9%� 0.8% (p �0.0028). On the other hand, the preoperativemean of 17.9% � 0.9% of forms with mid piece defects was18.2% � 0.7% at postoperative month 6 (p �0.05). Beforevaricocele repair mean tail defective was 8.4% � 1.1% andmean immature forms were 2.2% � 0.8%, which changed to7.0% � 1.0% and 2.0% � 0.9% after varicocelectomy, respec-

TABLE 1. General characteristics of the study population by grade

Varicocele Size

I II III

No. pts. 16 24 50Median age (range) 26 (22–42) 27 (21–38) 30 (22–36)Mean yrs. infertility � SD 3.8 � 1.0 4.7 � 1.6 5.1 � 1.1No. location:

Rt. 0 0 4Lt. 12 18 36Bilat. 4 6 10

EFFECTS OF VARICOCELECTOMY ON KRUGER MORPHOLOGY AND SEMEN1072

tively. Surgical repair of varicoceles did not cause significantimprovement in these forms (table 3).

Of the 36 group 1 patients 6 improved to group 4, 26improved to group 3 and 4 without significant changes re-mained in group 1. Of the 32 group 2 patients 18 improved togroup 4, 10 improved to group 3 and 4 remained unchanged.Of the 22 group 3 patients 6 achieved normal values (group4), 8 were improved but still less than 14% and 8 wereunaffected (table 4).

Pregnancy outcome. There were 18 pregnancies (20%) re-sulting in live birth in the 90 cases after varicocele repair. Of30 patients 14 (15.5%) conceived by natural intercourse and4 (4.44%) achieved pregnancy by intrauterine insemination.In group 4 there were 13 pregnancies, including 11 by natu-ral conception and 2 by intrauterine insemination. The 5group 3 pregnancies included 3 by natural intercourse and 2by intrauterine insemination.

DISCUSSION

Varicocele often causes disturbance in the spermatogenicprocess. The effect of varicocele on sperm production in sub-fertile men manifests with abnormal semen quality, includ-ing a low sperm count, decreased sperm motility and a highpercent of abnormal sperm forms.1, 2 The incidence of oligo-spermia and asthenospermia in our study group was 64.4%(29 patients) and 75.5% (68), respectively. Using the normalmorphological sperm ratio of greater than 14% all 90 patientshad abnormal preoperative sperm morphology.

Semen abnormalities represent the main indication forvaricocele surgery in infertile patients. There is disagree-ment on the nature of the improvement in sperm qualityafter high ligation. According to most reports approximatelytwo-thirds of the patients with varicocele show improvementin sperm quality after spermatic vein ligation.1, 11 Somegroups noted improvement in all sperm quantity and qualityparameters and some observed improvement only in spermdensity or the motility index, whereas others claimed thatthe sperm does not show any quantitative or qualitativeimprovement.5 In a review of 15 published reports on 2,466infertile men with varicoceles Pryor and Howards noted im-proved semen parameters in 66% after varicocele ligation.2However, most reviewed studies did not include an untreatedcontrol group. In 2 more recent randomized controlled stud-ies no alteration in sperm parameters was observed in thecontrol groups during 1 year of followup, whereas the totalsperm count improved significantly in treated patients.12, 13

Improved sperm motility is not a consistent result of varico-cele surgery and it was only statistically significant in 1 ofthese 2 studies.13 The ambiguity of the reported results maybe due to lack of uniformity in patient selection, followup,

reliability of diagnostic and therapeutic methods, criteria forsuccess or statistical method.14 In our study the preoperativemean sperm concentration of 22.1 � 4.2 million per ml.increased to 38.3 � 6.1 million per ml. at postoperativemonth 6. Postoperative improvement was noted in 44 of the58 patients (75.8%) with a preoperative sperm concentrationof less than 20 million per ml. On the other hand, 68 patientshad abnormal sperm motility. Sperm motility increased froma mean of 23.2% � 2.2% to 45.1% � 1.9% at postoperativemonth 6. Postoperative improvement was noted in 40 of these68 patients (58.8%). Our finding that varicocele ligation im-proves sperm count and motility is in agreement with themajority of reports.

There are few studies in the literature of the effect ofvaricocelectomy on morphological characteristics evaluatedwith Kruger strict criteria. Vazquez-Levin and et al notedthat surgical correction in 33 subfertile men with varicocelewas associated with significant improvement in sperm mor-phology according to the Kruger classification.6 Seftel et alreported that sperm morphology measured by strict morpho-logical criteria did not improve after varicocelectomy butthere were highly significant changes in motility and concen-tration.15 In our study normal morphological sperm levelsand the rate of forms with head, acrosome and mid piecedefects improved significantly at postoperative month 6 butsurgical repair of varicocele did not result in significant im-provement in forms with tail defects or immature forms.Unfortunately there are patients who do not seem to benefitfrom surgical correction of varicoceles. It has previously beenpostulated that failure to respond to varicocelectomy in somecases may be attributable to irreversible damage or to someother unknown coexisting damaging process.16

Although the number of controlled studies was limited,there have been many uncontrolled studies of the effect ofsurgical correction of varicoceles on infertility. Pryor andHowards evaluated the success of varicocele surgery andobserved an overall reported pregnancy rate of 43%.2 Othercontrolled studies showed improved seminal variables andpregnancy rates in patients treated with varicocelectomycompared with those who did not undergo varicocele liga-tion.1 The randomized prospective study of patients withvaricocele of Madgar et al comparing those treated withsurgery versus simple observation alone clearly shows thatvaricocelectomy improves sperm variables and fertilityrates.13

There are also few studies in the literature of the effect ofvaricocelectomy on Kruger morphology and fertility together.At the beginning of our study we selected patients with anormal morphological sperm ratio of less than 14%, so thatnone had normal Kruger morphology preoperatively. Accord-ing to the study of Kruger et al the in vitro fertilization ratein men with a normal morphological sperm ratio of less than4% is 7.6%, although in those with 4% to 14% normal mor-phology this rate was 64%.7,8 Men with normal morphologygreater than 14% had an in vitro fertilization rate similar tothe laboratory normal range. In our study 36 patients ingroup 1 and 32 in group 2 had a normal morphological spermratio of less than 4% with an in vitro fertilization rate of 7.6%preoperatively. In 22 men in group 3 the in vitro fertilizationrate was 64%. When we evaluated postoperative results,there were 4, 4, 52 and 30 patients in groups 1 to 4, respec-tively. A total of 14 pregnancies (15.5%) were achieved by

TABLE 2. Semen parameters before and after varicocelectomy

Parameter Mean Preop.� SD

Mean 6 Mos.Postop. � SD p Value

Semen vol. (ml.) 2.8 � 0.2 2.6 � 0.3 �0.05Sperm concentration (million/ml.) 22.1 � 4.2 38.3 � 6.1 �0.0002% Sperm motility 23.2 � 2.2 45.1 � 1.9 �0.0001

TABLE 3. Sperm morphology evaluated using the Krugerclassification in the study group before and after varicocelectomy

Forms Mean %Preop. � SD

Mean % 6Mos. Postop.

� SDp Value

Normal morphology 2.6 � 0.5 10.2 � 0.9 �0.0001Head defects 55.2 � 3.4 22.7 � 2.9 �0.0014Acrosomal defects 16.8 � 1.7 8.9 � 0.8 �0.0028Mid piece defects 17.9 � 0.9 18.2 � 0.7 �0.05Tail defects 8.4 � 1.1 7.0 � 1.0 �0.05Immature/other 2.2 � 0.8 2.0 � 0.9 �0.05

TABLE 4. Preoperative and postoperative ratio of morphologicallynormal sperm according to strict morphological criteria

Group Ratio (%) No. Preop. No. 6 Mos. Postop.

1 0 36 42 4 or Less 32 43 4–14 22 52 (26 � 10 � 8 � 8)4 14 or Greater 0 30 (6 � 18 � 6)

EFFECTS OF VARICOCELECTOMY ON KRUGER MORPHOLOGY AND SEMEN 1073

natural conception after varicocele repair in these cases withno chance of preoperative natural conception and there werean additional 4 pregnancies (4.4%) by intrauterine insemina-tion. Consequently the fertility rate after varicocele repairwas 20% (16 cases). Because varicocelectomy normalized theKruger morphology and enhanced the response to fertiliza-tion in vitro, we think that this procedure is valuable. Theurologist goal for infertile males is to improve the quality ofsperm sufficiently to enable the couple to conceive with theleast invasive and most economical method. Based on theseminal improvements in our study we currently recom-mended varicocelectomy in patients with a normal morpho-logical sperm ratio of less than 14%. We hoped that it wouldallow them to conceive with less invasive and less costlytechniques, such as intrauterine insemination or naturalconception, avoiding in vitro fertilization/intracytoplasmicsperm injection techniques. In conclusion, varicocelectomyenables infertile patients with clinical varicocele to improvethe likelihood of pregnancy through natural conception aswell as increase the chance of conception by a less invasiveand less costly technique.

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14. Pierik, F. H., Vreeburg, J. T., Stıjnen, T., Van Roıjen, J. H.,Dohle, G. R., Lameris, J. S. et al: Improvement of sperm countand motility after ligation of varicoceles detected with colourDoppler ultrasonography. Int J Androl, 21: 256, 1998

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