Table of Contents  
INVITED REVIEW
Year : 2016  |  Volume : 18  |  Issue : 2  |  Page : 179-181

Epidemiology of varicocele


1 Division of Urology, Department of Surgery, McGill University, Montreal, Québec, Canada
2 Department of Urology, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
3 Department of Radiology, Research Centre of the University of Montreal Hospital Centre, Québec, Canada

Date of Submission23-Nov-2015
Date of Decision06-Dec-2015
Date of Acceptance11-Dec-2015
Date of Web Publication08-Jan-2016

Correspondence Address:
Prof. Armand Zini
Division of Urology, Department of Surgery, McGill University, Montreal, Québec
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1008-682X.172640

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  Abstract 

Varicocele is a common problem in reproductive medicine practice. A varicocele is identified in 15% of healthy men and up to 35% of men with primary infertility. The exact pathophysiology of varicoceles is not very well understood, especially regarding its effect on male infertility. We have conducted a systematic review of studies evaluating the epidemiology of varicocele in the general population and in men presenting with infertility. In this article, we have identified some of the factors that can influence the epidemiological aspects of varicoceles. We also recognize that varicocele epidemiology remains incompletely understood, and there is a need for well-designed, large-scale studies to fully define the epidemiological aspects of this condition.

Keywords: epidemiology; infertility; varicocele


How to cite this article:
Alsaikhan B, Alrabeeah K, Delouya G, Zini A. Epidemiology of varicocele. Asian J Androl 2016;18:179-81

How to cite this URL:
Alsaikhan B, Alrabeeah K, Delouya G, Zini A. Epidemiology of varicocele. Asian J Androl [serial online] 2016 [cited 2021 Nov 28];18:179-81. Available from: https://www.ajandrology.com/text.asp?2016/18/2/179/172640 - DOI: 10.4103/1008-682X.172640


  Introduction Top


A varicocele is defined as an abnormal venous dilatation and/or tortuosity of the pampiniform plexus in the scrotum. Although varicoceles are almost always larger and more common on the left side, up to 50% of the men with varicocele, have bilateral varicoceles. [1] The rare, isolated right sided varicocele generally suggests that the right internal spermatic vein enters the right renal vein, but it should prompt further investigation as this finding may be associated with situs inversus or retroperitoneal tumors. It is generally reported that varicoceles are present in 15% of the general male population, in 35% of men with primary infertility, and in up to 80% of men with secondary infertility. [2],[3],[4]

The etiology of varicocele is though to be multi-factorial. The anatomic differences in venous drainage between the left and right internal spermatic vein (accounting for the predominance of left sided varicocele), and, the incompetence of venous valves resulting in reflux of venous blood and increased hydrostatic pressure are the most quoted theories for varicocele development. [5],[6] Physical exertion during puberty may lead to the development of varicocele whereas physical exertion at a later age can aggravate the condition but does not modify the prevalence of varicocele. [7],[8]

Investigators have proposed several mechanisms to explain the pathophysiology of varicocele. Scrotal hyperthermia likely represents the primary mechanism by which a varicocele affects endocrine function and spermatogenesis, both sensitive to temperature elevation. [9],[10],[11],[12] The reflux of adrenal and renal metabolite (supported by early anatomic radiographic studies) is another potential mechanism. [13],[14],[15],[16] Increased hydrostatic pressure in the internal spermatic vein from renal vein reflux may also be responsible for varicocele-induced pathology. [17]

The exact pathophysiology of varicocele, specifically, the influence of varicoceles on male fertility potential has not been established conclusively. To date, several studies have demonstrated an association between varicocele and reduced male fertility potential (e.g., poor semen parameters, infertility). However, most varicocele studies involve highly selected populations (e.g., infertile men) and rarely examine unselected men, representing an important reason for the difficulty in relating varicoceles with male fertility. [18]

Clinical (palpable) varicoceles are detected and graded based on physical examination: a grade 1 clinical varicocele is one that is only palpable during the Valsalva maneuver, a grade 2 varicocele is easily palpable with or without Valsalva but is not visible, while grade 3 refers to a large varicocele that is easily palpable and detected by visual inspection of the scrotum. [19] Despite having a varicocele grading system [19] it is important to recognize that epidemiological studies may report variable results due to variations in the detection of varicocele.

The focus of this chapter is to examine and report on the epidemiology of varicoceles in the general male population and in infertile men.


  Methods Top


Initially, a MEDLINE search was performed including articles from 1992 to 2015. The MEDLINE search terms included: "varicocele," "epidemiology," and "infertility." To widen the search scope, EMBASE and Google Scholar search engines were used, as well as, major references of reviewed articles. Abstracts of more than 140 articles were identified, and a total of 82 articles were reviewed. The main focus was on articles discussing the epidemiological aspect of clinical varicoceles and their relationship to male infertility/subfertility.


  Epidemiology Of Varicocele - Clinical Factors Top


Prevalence of varicocele in the general male population

Most of the early epidemiological studies on varicocele evaluated the prevalence of this condition in young men (military recruits, adolescent school boys, prevasectomy). These early studies reported that the prevalence of varicocele in the general male population is about 15%. [2],[20],[21],[22],[23],[24] These early observations did not suggest that age was an important determinant of varicocele prevalence.

Subsequent epidemiological studies have demonstrated that varicoceles develop at puberty. Oster observed that no varicoceles were detected in 188 boys 6-9 years of age, but were detected with increasing frequency in boys 10-14 years of age, strongly suggesting that varicoceles develop at puberty. [25] More recently, Akbay et al. [26] evaluated the prevalence of varicoceles in 4052 boys aged 2-19. They reported that the prevalence of varicoceles was <1% in boys aged 2-10, 7.8% in boys aged 11-14 years and 14.1% in boys aged 15-19 years. These epidemiological observations suggest that the venous incompetence that is characteristic of varicocele primarily occurs during testicular development.

More recent studies suggest that the prevalence of varicoceles in adult men is age-related. Levinger et al. evaluated the age-related prevalence of varicoceles in men above the age of 30. [27] Out of 504 healthy men, 34.7% were found to have a varicocele on physical examination (with all examinations performed by the same investigator). On further analysis, they observed that the prevalence of varicocele increases by approximately 10% for each decade of life. Varicocele prevalence was 18% at age 30-39, 24% at age 40-49, 33% at age 50-59, 42% at age 60-69, 53% at age 70-79 and 75% at age 80-89. [27] Canales et al. reported a relatively high prevalence (42% prevalence) of varicocele in older men presenting to a prostate cancer screening program (mean age 60.7 years). [28] However, unlike the study of Levinger et al. the report of Canales et al. did not demonstrate an age-related increase in varicocele prevalence in their cohort likely because most men in their study were elderly. These epidemiological observations suggest that testicular venous incompetence increases with age, likely a result of the aging of venous valves. These data are in keeping with the age-related increase in the prevalence of lower limb varicose veins. [29]

Prevalence of varicocele in a population of infertile men

The prevalence of varicocele in men presenting for infertility is in the range of 25%-35%, and in that subset of men with secondary infertility it is 50%-80%. [3],[30] In 1992, the World Health Organization (WHO) conducted a large study in 34 centers over a 12-month period. [30] Men consulting for infertility evaluation were screened using a standardized protocol common to all participating centers. The WHO investigators evaluated 9034 men and reported that 25.4% of the men with an abnormal semen analysis had a varicocele. In contrast, in the same study, the prevalence of varicocele in men with a normal semen analysis was 11.7%. [30]

Gorelick and Goldstein evaluated 1001 infertile men and reported that the prevalence of varicocele is 35% in men with primary infertility and 81% in men with secondary infertility. [3] Similarly, Witt and Lipshultz evaluated 2989 infertile men and reported that a varicocele is identified in 69% of men with secondary infertility. [4] These two groups of investigators concluded that in some men, a varicocele is a progressive and not a static lesion resulting in the loss of previously established fertility. However, given the subsequent observations of Levinger et al. [27] it is also possible that the increased prevalence of varicocele in some men with secondary infertility is a result of the age-related increase in the prevalence of a varicocele as these men tend to be older than men with primary infertility. [3],[31]

Venous insufficiency

An association between varicose veins of lower extremities and varicoceles has been suggested. Yasim et al. reported on 100 patients undergoing surgical repair of varicose veins, of which 72% had varicoceles with multiple degrees of severity, suggesting a common origin, likely incompetent venous valves. [32] As suggested by Levinger et al. [27] in their study on the age-related increase in varicocele prevalence, systemic venous insufficiency may be at the root of both lower venous incompetence and testicular venous incompetence.

Body mass index (BMI)

Most studies on the subject of BMI have reported an inverse relationship between the prevalence of varicocele and BMI. Although some studies have found no significant differences in BMI between men with and without varicocele, [33],[34] other studies have reported that men with varicocele have lower BMI than men without varicocele, [35],[36] or that the prevalence of varicocoele decreases as BMI increases. [37],[38],[39],[40],[41],[42],[43]

The inverse relationship between the prevalence of varicocele and BMI may be due to detection bias. It is possible that the proper detection of a varicocele may be more difficult in obese patients (due to a thicker spermatic cord) and this may lead under-detection of varicocele in these men. However, investigators have also suggested that the "nutcracker" phenomenon (thought to be responsible for compression of the spermatic vein) may be dampened in obese men due to increased intra-abdominal adiposity. [37],[38]

Hereditary factors

Raman et al. reported on the hereditary patterns of varicoceles. [44] They concluded that 56% of first-degree relatives of patients with varicoceles had a palpable varicocele, which was 8-fold higher than their control group (men presenting for vasectomy reversal). [44] Mokhtari et al. also showed a 45% prevalence of varicoceles among first-degree relatives, compared to 11% in their control group (population of healthy men serving as kidney donors). [45] More recently in 2010, Gökçe et al. reported a prevalence of 34% among first-degree relatives and this was significantly different than their control group (population of healthy men). [46] These studies strongly suggest that the prevalence of varicocele can be influenced by hereditary factors. The specific genetic factors associated with the increased prevalence of varicocele among family members remains to be elucidated.

Limitations of existing studies

The published studies on varicocele prevalence in fertile and infertile men have provided us with a good insight into the epidemiological aspects of this condition. However, there are several limitations that need to be recognized regarding the available studies on varicocele epidemiology. One of the main limitations of these epidemiological studies is that comparison of the general male population and the infertile male population is mostly indirect because few studies examine varicocele prevalence in both of these groups. This is important because the diagnosis of varicocele greatly depends on the expertise of the clinician performing the physical exam and establishing the diagnosis may vary from center to center. Failure to carefully define the study populations (e.g., age, semen parameters, hereditary factors, co-existing venous insufficiency, BMI) is another important limitation of the available studies. These limitations would best be addressed by performing studies that carefully define the study population(s), physical examination findings (with inter-observer variability) and control for important clinical parameters (e.g., age, semen parameters, hereditary factors, co-existing venous insufficiency, BMI).


  Conclusion Top


Varicocele epidemiology remains incompletely understood. We need well-designed, large-scale studies that include evaluation of important clinical factors to comprehend fully the epidemiological aspects of this condition. Future studies must carefully define the study population(s), physical examination findings (with inter-observer variability) and all pertinent clinical parameters (age, semen parameters, hereditary factors, co-existing venous insufficiency, BMI) to further advance our knowledge in this field.


  Competing Interest Top


All authors declare no competing interests.

 
  References Top

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22 Endoplasmic Reticulum Stress (ER Stress) and Unfolded Protein Response (UPR) Occur in a Rat Varicocele Testis Model
Mahshid Hosseini,Erfaneh Shaygannia,Mohsen Rahmani,Anahita Eskandari,Aram Ahmadzadeh Golsefid,Marziyeh Tavalaee,Parviz Gharagozloo,Joël R. Drevet,Mohammad H. Nasr-Esfahani
Oxidative Medicine and Cellular Longevity. 2020; 2020: 1
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23

Factors Associated with Varicocele Recurrence After Microscopic Sub-Inguinal Varicocelectomy

Mohammad Alkhamees,Saeed Bin Hamri,Turki Alhumaid,Layla Alissa,Haleema Al-Lishlish,Rula Abudalo,Zafar Iqbal,Ghufran Albajhan,Ahmed Alasker
Research and Reports in Urology. 2020; Volume 12: 651
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24 Varicocoele and oxidative stress: New perspectives from animal and human studies
Mazdak Razi,Marziyeh Tavalaee,Farshid Sarrafzadeh-Rezaei,Aron Moazamian,Parviz Gharagozloo,Joël R. Drevet,Mohammad-Hossein Nasr-Eshafani
Andrology. 2020;
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25 Male factor infertility trends throughout the last 10 years: Report from a tertiary-referral academic andrology centre
Giuseppe Fallara,Walter Cazzaniga,Luca Boeri,Paolo Capogrosso,Luigi Candela,Edoardo Pozzi,Federico Belladelli,Nicolò Schifano,Eugenio Ventimiglia,Costantino Abbate,Enrico Papaleo,Paola Viganò,Francesco Montorsi,Andrea Salonia
Andrology. 2020;
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26 Microsurgical varicocelectomy effect on sperm telomere length, DNA fragmentation and seminal parameters
Sandra Lara-Cerrillo,Josep Gual-Frau,Jordi Benet,Carlos Abad,Juan Prats,María José Amengual,Agustín García-Peiró
Human Fertility. 2020; : 1
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27 Association between seminal granulysin and malondialdehyde in infertile men with varicocele and the potential effect of varicocelectomy
Howyda M. Kamal,Asmaa A. El-Fallah,Shabieb A. Abdelbaki,Mostafa M. Khalil,Mai M. Kamal,Eman G. Behiry
Andrologia. 2020; : e13579
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28 Protein profiling in unlocking the basis of varicocele-associated infertility
Manesh Kumar Panner Selvam,Saradha Baskaran,Ashok Agarwal,Ralf Henkel
Andrologia. 2020;
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29 Effects of liver-regulating herb compounds on testicular morphological and ultrastructural changes in varicocele rats through SCF/C-KIT pathway
Xianfeng Lu,Jianrong Liu,Haizhen Yin,Caiyun Ding,Yimin Wang,Fang Zhang,Guorong Jin,Yuehong Ma,Lina Dong,Qin Qin
Andrologia. 2020;
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30 Etiologies of sperm DNA damage and its impact on male infertility
Manesh Kumar Panner Selvam,Rafael F. Ambar,Ashok Agarwal,Ralf Henkel
Andrologia. 2020;
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31 Assessment of seminal YKL-40 in infertile men with varicocele
Sherine H. Abd El Rahman,Laila A. Rashed,Essam M. Akl,Taymour Mostafa
Andrologia. 2020;
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32 Capsaicin improves sperm quality in rats with experimental varicocele
Mahshid Hosseini,Marziyeh Tavalaee,Mohsen Rahmani,Anahita Eskandari,Erfaneh Shaygannia,Abbas Kiani-Esfahani,Dina Zohrabi,Mohammad Hossein Nasr-Esfahani
Andrologia. 2020;
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33 Platelet indices and varicocele: A systematic review and meta-analysis
Yuyang Zhang,Xu Wu,Wei Zhang,Jingjing Gao,Yao Zhang,Xiansheng Zhang
Andrologia. 2020;
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34 Pain relief after varicocele embolization: The patient’s perspective
Mark Sheehan,Hayley Briody,Damien C O’Neill,Dermot Bowden,Niall F Davis,Mark Given,Ponnusamy Mohan,Michael J Lee
Journal of Medical Imaging and Radiation Oncology. 2020;
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35 Comparison of the efficacy and safety of microscopic and laparoscopic surgery for varicocele
Zixiang Li,Simeng Hu,Raorao Zhou,Junqi Wang
World Journal of Urology. 2020;
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36 Ultrasound evaluation of varicoceles: systematic literature review and rationale of the ESUR-SPIWG Guidelines and Recommendations
Michele Bertolotto,Simon Freeman,Jonathan Richenberg,Jane Belfield,Vikram Dogra,Dean Y. Huang,Francesco Lotti,Karolina Markiet,Olivera Nikolic,Subramaniyan Ramanathan,Parvati Ramchandani,Laurence Rocher,Mustafa Secil,Paul S. Sidhu,Katarzyna Skrobisz,Michal Studniarek,Athina Tsili,Ahmet Tuncay Turgut,Pietro Pavlica,Lorenzo E. Derchi
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37 Paying the price for standing tall: Fluid mechanics of prostate pathology
Yigal Gat,Sharon Joshua,Stanimir Vuk-Pavlovic,Menachem Goren
The Prostate. 2020;
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38 Right-sided scrotal varicocele and its association with malignancy: a multi-institutional study
Malak Itani,Benjamin Kipper,Michael T. Corwin,Constantine M. Burgan,David T. Fetzer,Anuradha S. Shenoy-Bhangle,Afnan Althubaity,Thomas W. Loehfelm,William D. Middleton,Ghaneh Fananapazir
Abdominal Radiology. 2020;
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39 Evaluation of the role of reflux pattern in Color Doppler Ultrasound on spermogram improvement after varicocelectomy
Meysam Salehzadeh,Sepideh Abdi Tazeabadi,Mansour Bahardoust,Zahra Bagheri-Hosseinabadi,Koosha Kamali,Mostafa Ghadamzadeh,Seyed Morteza Bagheri
International Urology and Nephrology. 2020;
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40 Die Varikozele – Wann und wie soll behandelt werden?
Janine Langenauer,Christoph Schwab
Urologie in der Praxis. 2020;
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41 Alpha-lipoic acid improves sperm motility in infertile men after varicocelectomy: a triple-blind controlled randomized trial
Behzad Abbasi,Newsha Molavi,Marziyeh Tavalaee,Homayoun Abbasi,Mohammad Hossein Nasr-Esfahani
Reproductive BioMedicine Online. 2020;
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42 Curated findings and implications in duplex ultrasound interrogation of the scrotum or varicoceles
Size Wu,Dongshen Zuo,Dongyan Cai,Qingfang Chen,Ya Li
Scientific Reports. 2020; 10(1)
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43 Molecular characteristics of varicocele: integration of whole-exome and transcriptome sequencing
Bo Yang,Yuan Yang,Yunqiang Liu,Hong Li,Shangqing Ren,Zhufeng Peng,Kun Fang,Luchen Yang,Qiang Dong
Fertility and Sterility. 2020;
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44 Scientific landscape of oxidative stress in male reproductive research: A scientometric study
Ashok Agarwal,Saradha Baskaran,Manesh Kumar Panner Selvam,Renata Finelli,Catalina Barbarosie,Kathy Amy Robert,Concetta Iovine,Kruyanshi Master,Ralf Henkel
Free Radical Biology and Medicine. 2020;
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45 Varicoceles
Samantha Kobeissi,Bill S. Majdalany,Abhishek K. Goswami,Christopher N. Kanaan,Nima Kokabi,Minhaj S. Khaja
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46 Open, Laparoscopic, and Microsurgical Varicocelectomy for Male Infertility: a Systematic Review and Meta-analysis
Qun Wang,Yanhong Liu,Libo Wang
Indian Journal of Surgery. 2019;
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47 Evaluation of the effects of antioxidant treatment on sperm parameters and pregnancy rates in infertile patients after varicocelectomy: a randomized controlled trial
Fuat Kizilay,Baris Altay
International Journal of Impotence Research. 2019;
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48 Ultrasound evaluation of varicoceles: guidelines and recommendations of the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) for detection, classification, and grading
Simon Freeman,Michele Bertolotto,Jonathan Richenberg,Jane Belfield,Vikram Dogra,Dean Y. Huang,Francesco Lotti,Karolina Markiet,Olivera Nikolic,Subramaniyan Ramanathan,Parvati Ramchandani,Laurence Rocher,Mustafa Secil,Paul S. Sidhu,Katarzyna Skrobisz,Michal Studniarek,Athina Tsili,Ahmet Tuncay Turgut,Pietro Pavlica,Lorenzo E. Derchi
European Radiology. 2019;
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49 Effect of silencing HIF-1a gene on testicle spermatogenesis function in varicocele rats
Wei Zhao,Jianrong Liu,Danfeng Wang,Yimin Wang,Fang Zhang,Guorong Jin,Caixia Yuan,Xin Wang,Qin Qin
Cell and Tissue Research. 2019;
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50 Should the current guidelines for the treatment of varicoceles in infertile men be re-evaluated?
Sylvia Yan,Maj Shabbir,Tet Yap,Sheryl Homa,Jonathan Ramsay,Kevin McEleny,Suks Minhas
Human Fertility. 2019; : 1
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51 Thiol–disulphide balance in infertility secondary to varicocele
Soner Coban,Yasemin Ustundag,Ali Riza Turkoglu,Muhammet Guzelsoy,Mustafa Murat Aydos,Ibrahim Keles,Ugur Akgun,Ahmet Rifat Balik,Ozcan Erel
Andrologia. 2019; : e13300
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52 Comparison between microsurgical varicocelectomy with and without testicular delivery for treatment of varicocele: A systematic review and meta-analysis
Yuxuan Song,Yi Lu,Yawei Xu,Yongjiao Yang,Xiaoqiang Liu
Andrologia. 2019;
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53 Lower body mass index and higher height are correlated with increased varicocele risk
Yuxuan Song,Yawei Xu,Zhen Liang,Yongjiao Yang,Xiaoqiang Liu
Andrologia. 2019;
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54 Relationship between varicocele and platelet indices: changes of mean platelet volume before and after operation
Q.-F. Zhang,J.-H. Liang,T.-H. He,Z.-X. Huang,Q.-L. Liu,X. Zhang,S.-L. Shen,G.-Y. Li,W.-R. Song
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55 Hesperidin attenuated apoptotic-related genes in testicle of a male rat model of varicocoele
M. Shokoohi,H. Shoorei,A. Khaki,A. A. Khaki,M. Moghimian,S.-H. Abtahi-Eivary
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56 Sperm phenotypes in varicocele
O. B. Zhukov,E. E. Bragina,A. V. Levin
Andrology and Genital Surgery. 2019; 20(4): 24
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57 Management and Treatment of Varicocele in Children and Adolescents: An Endocrinologic Perspective
Rossella Cannarella,Aldo E. Calogero,Rosita A. Condorelli,Filippo Giacone,Antonio Aversa,Sandro La Vignera
Journal of Clinical Medicine. 2019; 8(9): 1410
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58 Two Case Reports of Varicocele Rupture during Sexual Intercourse and Review of the Literature
Chalil Arif,Konstantinos Kotoulas,Chrysostomos Georgellis,Konstantinos Frigkas,Athanasios Bantis,Emmanouil Patris
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59 Assessment of seminal granulysin in infertile men with varicocele
Nancy W. Mikhael,Asmaa M. El-Refaie,Jehan H. Sabry,Essam M. Akl,Amal Y. Habashy,Taymour Mostafa
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60 Effects of microsurgical varicocelectomy on semen analysis and sperm function tests in patients with different grades of varicocele: Role of sperm functional tests in evaluation of treatments outcome
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61 A Novel Method for Investigating the Role of Reflux Pattern in Color Doppler Ultrasound for Grading of Varicocele
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62 An Infertile Coupleæs Long and Expensive Path to Varicocele Repairs
Adithya Balasubramanian,Nannan Thirumavalavan,Jason Scovell,Jonathan Lo,Byung Ji,Elizabeth L. Godfrey,Alexander W. Pastuszak,Larry I. Lipshultz
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63 Treating varicocele in 2018: current knowledge and treatment options
M. Zavattaro,C. Ceruti,G. Motta,S. Allasia,L. Marinelli,C. Di Bisceglie,M. P. Tagliabue,M. Sibona,L. Rolle,F. Lanfranco
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64 Proteomic Signatures of Sperm Mitochondria in Varicocele: Clinical Utility as Biomarkers of Varicocele Associated Infertility
Luna Samanta,Ashok Agarwal,Nirlipta Swain,Rakesh Sharma,Banu Gopalan,Sandro C. Esteves,Damayanthi Durairajanayagam,Edmund Sabanegh
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65 Laparoscopic versus open Varicocelectomy: An Observational Study
Shaukat Jeelani,Atif Naeem,Ishfaq A Gilkar,Javid A Peer,Umer Mushtaq
World Journal of Laparoscopic Surgery with DVD. 2018; 11(2): 76
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66 Potential role of imaging in assessing harmful effects on spermatogenesis in adult testes with varicocele
Athina C Tsili,Olga N Xiropotamou,Anastasios Sylakos,Vasilios Maliakas,Nikolaos Sofikitis,Maria I Argyropoulou
World Journal of Radiology. 2017; 9(2): 34
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67 Unilateral right-sided varicocele associated with pancreatic cancer: A cadaveric case report
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68 Indocyanine Green Angiography-assisted Laparoendoscopic Single-site Varicocelectomy
Keiji Tomita,Susumu Kageyama,Eiki Hanada,Tetsuya Yoshida,Yuki Okinaka,Shigehisa Kubota,Masayuki Nagasawa,Kazuyoshi Johnin,Mitsuhiro Narita,Akihiro Kawauchi
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69 Determination of spermatic vein reflux after varicocele repair helps to define the efficacy of treatment in improving sperm parameters of subfertile men
S. D’Andrea,A. Micillo,A. Barbonetti,A. V. Giordano,S. Carducci,A. Mancini,S. Necozione,F. Francavilla,S. Francavilla
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70 The impact of coexisting sperm DNA fragmentation and seminal oxidative stress on the outcome of varicocelectomy in infertile patients: A prospective controlled study
Shabieb A. Abdelbaki,Jehan H. Sabry,Ahmed M. Al-Adl,Hanan H. Sabry
Arab Journal of Urology. 2017; 15(2): 131
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71 Varicocele embolization with glue and coils: A single center experience
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72 Adjuvant Treatment with Qilin Pill for Men with Oligoasthenospermia: A Meta-Analysis of Randomized Controlled Trials
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73 The Dilemma of Adolescent Varicoceles: Do They Really Have to Be Repaired?
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74 The Role of Varicocele in Male Factor Subfertility
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75 Prevalence of varicocoele and its association with body mass index among 39,559 rural men in eastern China: a population-based cross-sectional study
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76 Autophagy may play an important role in varicocele
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77 Varicocele and male infertility: current concepts and future perspectives
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78 Afterword to varicocele and male infertility: current concepts and future perspectives
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79 Risk of varicocele in patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic disease: a population-based case–control study
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80 Beneficial effects of microsurgical varicocoelectomy on sperm maturation, DNA fragmentation, and nuclear sulfhydryl groups: a prospective trial
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81 Effect of Varicocelectomy on Serum FSH and LH Levels for Patients with Varicocele: a Systematic Review and Meta-analysis.
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82 Varicocele in a Young Man: Something We Should Be Worried About?
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