Stesura Seveso Archivio Italiano di Urologia e Andrologia 2025; 97(2):13938 1 ORIGINAL PAPER been found in about 15% of the general male populations (3-5). Men with varicoceles typically seek medical assis- tance when they encounter symptoms such as pain or a dragging sensation in the scrotum. It's notable that up to 40% of men assessed at subfertility clinics are diagnosed with varicocele (6). Numerous theories have been pro- posed to explain the relationship between varicocele and infertility, with the primary factors including sperm dam- age due to increased scrotal temperature, accumulation of waste products in the sluggish blood flow of the pampini- form plexus, and elevated concentrations of testosterone and other hormones within these vessels (7-11). Various surgical methods are available for varicocele management, aiming to alleviate pain, remove the mass, and enhance semen parameters. However, despite varicocele being con- sidered one of the most treatable causes of male infertility, debates and uncertainties persist regarding its treatment (12). A common abnormality observed in individuals with varicocele is a reduction in sperm motility, present in approximately 90% of patients (13). Moreover, abnormali- ties in sperm morphology are also prevalent. Currently, there is no established correlation between the grade of varicocele, testicular pathology, and abnormalities in semen parameters (14). PATIENTS AND METHODS This study was carried out from February 2021 to August 2024 on 162 patients who presented at Thumbay univer- sity hospital seeking advice for infertility (primary or sec- ondary). The patients were subjected to history taking, clinical examination, semen analysis, colour Doppler ultrasonography (scrotal). Patients with recurrent varico- cele, azoospermia or have cause of infertility other than varicocele were excluded from the study. At least 2 semen analyses were done for all patients before operation and 3 Objectives: To assess the effectiveness of laparoscopic varicocelectomy in patients with clinical versus subclinical varicocele concerning preoperative and postoperative seminal parameters. Patients and methods: Between February 2021 and August 2024, a total of 162 patients diagnosed with varicocele (72 with subclinical and 90 with clinical presentation) seeking infertility advice (primary or secondary) at the author's institution under- went laparoscopic varicocelectomy and were enrolled in the study. All patients underwent history taking, clinical examina- tion, semen analysis, and scrotal colour Doppler ultrasonogra- phy. Patients with recurrent varicocele, azoospermia, or infertil- ity due to causes other than varicocele were excluded from the study. Semen analysis was conducted for all patients before laparoscopic varicocelectomy and 3 to 6 months after varicoc- electomy. Results: Significant improvements in seminal parame- ters were observed in patients with clinical varicocele (p < 0.05). Bilateral and right-sided varicoceles were more prevalent in patients with subclinical varicocele. Additionally, the incidence of secondary infertility was higher in patients with subclinical varicocele compared to those with clinical varicocele (p < 0.05). Conclusions: Our study indicates favourable outcomes of laparo- scopic varicocelectomy in patients with clinical varicocele. Regarding the effects of varicocelectomy in patients with subclin- ical varicocele, we recommend avoiding varicocelectomy in sub- clinical group of patients unless no identifiable causes of semen abnormality. KEY WORDS: Semen; Subclinical varicocele; Infertility. Submitted 30 April 2025; Accepted 1 June 2025 INTRODUCTION Varicocele is a state of dilated, elongated and tortuous veins of the pampiniform plexus of the spermatic cord (1, 2). Varicoceles typically develop during adolescent and have The changes of semen parameters of patients with clinical versus subclinical varicocele managed by laparoscopic varicocelectomy: Observational study Tamer A. Abouelgreed 1, 2, Mohamed A. Abdelaal 1, Mohamed A. Amer 3, Hassan Mamdouh 3, Ahmed F. El-Sherbiny 4, Emad Elrewiny 3, Ahmed E. Elsaadany 3, Waleed A. Mahmoud 5, Mohamed S. Hasan 3, Mostafa T. Eldestawy 3, Hazem B. Zakaria 3, Shaimaa H. Mohamed 6, Mosab F. Alassal 7, Hany Elsegeay 8, Mohamed Y. Elamir 9 1 Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt; 2 Department of Urology, Faculty of Medicine, Gulf Medical University, Ajman, UAE; 3 Department of Dermatology, Venereology & Andrology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt; 4 Department of Andrology, International Islamic Centre for Population Studies and Research, Al-Azhar University, Cairo, Egypt; 5 Department of Dermatology, Venereology & Andrology, Faculty of Medicine, Al-Azhar University, Asyut, Egypt; 6 Department of Dermatology & Venerology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt; 7 Department of Vascular Surgery, Lister hospital, Stevenage, United Kingdom; 8 Department of Urology, Faculty of Medicine, Al-Azhar University, Asyut, Egypt; 9 Department of Andrology, Faculty of Medicine, Cairo University, Cairo, Egypt. DOI: 10.4081/aiua.2025.13938 Summary Archivio Italiano di Urologia e Andrologia 2025; 97(2):13938 T.A. Abouelgreed, M.A. Abdelaal, M.A. Amer, et al. 2 to 6 months after operation. The patients were divided into 2 groups according to the degree of varicocele. Group A (90 patients with clin- ical varicocele) and Group B (72 patients with subclinical varicocele). The seminal parame- ters before and after the operation were com- pared among patients of each group. In both groups, varicocelectomy was done using laparoscopic approach for all patients by a sin- gle surgeon. Clinical varicocele was classified according to Dubin system into three grades. Grade I: small, palpable with only Valsalva manoeuvre; Grade II: moderate, palpable with patient standing and Grade III: large, visible through scrotal skin, and palpable with patient standing. Subclinical varicoceles are not palpa- ble on physical examination but rather are diagnose radiographically. After obtaining informed consent and performing clinical evaluation, for each patient a questionnaire regarding demographic fea- tures, marital situation, type of varicocele, genital evalua- tion and type of infertility (primary or secondary) was filled out. To ensure the accuracy of the study, a single medical technologist performed all laboratory experiments and a single urologist performed all operations. The spermiogram results pre and post-operative were compared among individuals of each group. Statistical analysis Statistical analysis was performed using the ‘Statistical Package for the Social Sciences’ software for Windows (version 26.0; SPSS Inc.). For all comparisons, p < 0.05 was considered statistically significant. RESULTS In our study we select a total of 162 men, suffering from varicocele. Their mean age was 28.7 ± 3.9 years. The largest age group belonged to those who were 40 years and younger, making up 94.64 % of group A patients and 94.5% of group B (Table 1). The affected side in the patients is shown in Table 2. In patients of group A, 21 (23.33%) had grade I, 41 (45.56%) had grade II and 28 (31.11%) hade grade III varicocele. Among patients of our study, the period of time from marriage to the first visit to the urology clinic regarding infertility was 3.4 ± 1.2 years in group A patients and 1.6 ± 1.9 years in group B patients, with a significant P value of < 0.001. In group A patients, 78.2% had primary and 21.8% had secondary infertility. Among group B patients, 25.3% had primary infertility, 74.7% had secondary infertility. Comparison of spermiogram parameters before and after varicocelectomy between individuals of each group is shown in Table 3. The main complications after operation in both groups were testicular pain and sensitivity in 19 patients (14 group A and 5 group B), mild hydrocele in 17 (6 group A and 11 group B), testicular atrophy in 3 (all of group B) and recur- rence of varicocele in 8 (3 group A and 5 group B). DISCUSSION Primary infertility remains a major challenge facing the world today. Studies have shown that approximately 15% of married couples suffer from infertility, with male caus- es, especially varicocele, accounting for 20% to 50% of cases (15, 16). In men with secondary infertility, this pro- portion increases to 80% (17). There is evidence that men with normospermic varicocele respond differently to varicocele resection than patients with preoperative oligo- zoospermia due to different pathophysiological mecha- nisms (18). Two important studies examined outcomes after varicocele repair in patients with normal sperm count. In one case, isolated teratozoospermia showed no significant improvement after varicocele resection; in another case, neither teratozoospermia nor astheno- zoospermia showed any improvement (19, 20). Furthermore, the authors claimed that undergoing varic- ocele resection puts this group of patients at risk for oligozoospermia. The approach to treating varicocele has changed significantly since Tulloch first proposed the association between varicocele and infertility in 1952 (21). Scott's 1961 study of 108 patients with varicocele concluded that larger varicoceles cause greater damage (22). Despite advances in imaging and understanding over the past six decades, the treatment of non-palpable varicocele remains controversial. Although there are sev- Table 3. Comparing the semen parameters between the groups of patients. Sperm parameters Groups Preoperative Postoperative P value values values Total sperm count (million per ml) A-I 21.61 ± 22.75 49.65 ± 16.95 < 0.05 A-II 19.8 ± 33.2 47.4 ± 15.92 < 0.05 A-III 16.1 ± 28.1 37.23 ± 18.7 < 0.05 B 20.9 ± 15.6 22.7 ± 12.8 NS Percentage of motile sperms A-I 48.75 ± 23.85 53.85 ± 21.07 NS A-II 40.27 ± 19.25 63.6 ± 19.9 < 0.05 A-III 38.7 ± 16.2 71.45 ± 12.25 < 0.05 B 58.4 ± 11.2 59.6 ± 8.9 NS Percent of sperm with normal morphology A-I 57.75 ± 19.45 58.35 ± 13.51 NS A-II 52.76 ± 18.35 53.7 ± 17.4 NS A-III 50.21 ± 19.46 50.16 ± 18.65 NS Table 1. Age distribution between patients of both groups. Age Group A (n = 90) Group B (n = 72) T < 20 14 (15.6%) 7 (9.7%) 21-30 63 (70%) 56 (77.8%) 31-40 8 (8.8%) 5 (7%) > 40 5 (5.6%) 4 (5.5%) Table 2. Side distribution of varicocele between patients of both groups. Side of varicocele Group A (n = 90) Group B (n = 72) Right 9 (10%) 16 (22.2%) Left 5 (5.6%) 24 (33.3%) Bilateral 78 (84.4%) 32 (44.5%) Archivio Italiano di Urologia e Andrologia 2025; 97(2):13938 3 Semen parameters after laparoscopic varicocelectomy eral grading systems, the Dublin grading system, which takes into account visibility and palpability, is widely accepted and classifies varicocele into three grades: grade 1 (palpable during Valsalva manoeuvre), grade 2 (palpa- ble in upright position) and grade 3 (visible and palpable at rest) (23). Research indicates that varicoceles, regard- less of their size, are associated with changes in semen parameters (24, 25). However, urologists need to consid- er Sub-Clinical Varicocele (SCV), which cannot be detected through visual or tactile examination but requires Doppler ultrasound for identification (26). Since the majority of studies focus on varicoceles diagnosed clini- cally, there is ongoing debate regarding the optimal man- agement of SCV. This study deals into the prevalence of infertility, the impact of SCV, and the controversies sur- rounding its diagnosis and treatment within our commu- nity. While varicocele represents a significant and com- mon factor in male infertility, clinical varicoceles can for- tunately be effectively treated following certain paraclini- cal diagnoses such as abnormalities in sperm analysis and/or sonogram results. Various publications express many different views regarding surgical outcomes in patients with subclinical varicocele (27-29). In our research, varicocelectomy did not show favorable out- comes among patients with subclinical varicocele. This finding aligns with the results reported by Bsat and Masabni, who similarly observed no positive outcomes following varicocelectomy in patients with subclinical varicocele (30). Conversely, Pierik et al., in their study involving patients with both clinical and subclinical varic- ocele, demonstrated that surgical intervention yielded consistent positive outcomes irrespective of the type of the condition (31). Many studies have sought to evaluate the impact of varicocelectomy on patients with subclini- cal varicocele. Among these studies, Unal et al. conduct- ed a comparison of two treatment methods for patients with subclinical varicocele: prescribing clomiphene to one group and performing varicocelectomy on the other group. They observed improvements in spermiogram parameters in both groups, with no significant difference between the two treatment methods (32). In our study, bilateral or left-sided varicoceles were relatively more common in group B compared to the clinical group, and baseline spermiograms of subclinical patients were less abnormal than those of patients in group A. Based on our findings and those of previous studies, it can be inferred that the underlying mechanisms and pathogenesis of left- sided subclinical varicoceles, as well as those with severe spermiogram abnormalities (similar to clinical varico- cele), resemble those of clinical varicocele, suggesting that surgery may yield better outcomes. However, in our study, a majority of the patients were affected on the left or both sides, indicating that other mechanisms may have influenced their sperm parameters. CONCLUSIONS Laparoscopic varicocelectomy shows favourable outcome in patients with clinical varicocele, while in patients with subclinical varicocele there was no significant effect of varicocelectomy, so, we recommend avoiding varicocelec- tomy in patients with subclinical varicocele to avoid the possible complications that might be occur from such surgery. REFERENCES 1. Baazeem A, Belzile E, Ciampi A, et al. 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Improvement of sperm count and motility after ligation of varicoceles detected with colour Doppler ultrasonography. Int J Androl. 1998; 21:256-260. 32. Unal D, Yeni E, Verit A, Karatas OF. Clomiphene citrate versus varicocelectomy in treatment of subclinical varicocele: a prospective randomized study. Int J Urol. 2001; 8:227-230. Correspondence Tamer A. Abouelgreed (Corresponding Author) dr_tamer_ali@yahoo.com; tamerali.8@azhar.edu.eg Department of Urology, Al-Azhar University, Cairo, Egypt, & Gulf Medical University, Ajman, UAE Mohamed A. Abdelaal maal_uro@yahoo.com Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Mohamed A. Amer amerrom@yahoo.com Hassan Mamdouh hsdermaclinic@yahoo.com Emad Elrewiny emad.elrewiny@yahoo.com Ahmed E. Elsaadany drhousesaadany@gmail.com Mohamed S. Hasan mohamed.saeed80@gmail.com Mostafa T. Eldestawy mostafa.eldestawy@azhar.edu.eg Hazem B. Zakaria hazem.basuny.1988@gmail.com Department of Dermatology, Venereology & Andrology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Ahmed F. El-Sherbiny Ahmed_derma@yahoo.com Department of Andrology, International Islamic Center for Population Studies and Research, Al-Azhar University, Cairo, Egypt Waleed A. Mahmoud waleedderma44@gmail.com Department of Dermatology, Venereology & Andrology, Faculty of Medicine, Al-Azhar University, Asyut, Egypt Shaimaa H. Mohamed shaimaadiab08@gmail.com Department of Dermatology & Venerology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt Mosab F. Alassal mosabalassal32@gmail.com Department of Vascular Surgery, Lister Hospital, Stevenage, United Kingdom Hany Elsegeay docterhany53@gmail.com Department of Urology, Faculty of Medicine, Al-Azhar University, Asyut, Egypt Mohamed Y. Elamir yousry82@kasralainy.edu.eg Department of Andrology, Faculty of Medicine, Cairo University, Cairo, Egypt