Effect of Varicocelectomy on Spermatogenic Cell Count and Semen Parameters

Male factor infertility contributes as the sole factor in approximately 20-25% of infertile couples. While semen analysis remains the cornerstone for evaluating male infertility , conventional parameters may not fully reflect underlying functional and molecular alterations. Varicocele, characterized by abnormal dilatation and tortuosity of the pampiniform venous plexus, is one of the most common correctable causes of male infertility. The pathological changes associated with varicocele can adversely affect the seminiferous epithelium, leading to defective spermatogenesis and an increased sloughing of immature germ cells (spermatogenic cells) into the seminal fluid. According to World Health Organization (WHO) recommendations, the presence of these spermatogenic cells is clinically relevant as it reflects impaired spermatogenesis and testicular dysfunction.

This prospective interventional study aims to evaluate changes in seminal spermatogenic cell counts and conventional semen parameters following surgical correction. Participants will undergo a subinguinal microsurgical varicocelectomy. During the procedure, the spermatic cord is delivered and examined under 5-10X microscopic magnification. The internal spermatic artery is carefully identified, utilizing an intraoperative USG probe if necessary, and dissected free of surrounding structures. Internal spermatic veins and cremasteric veins are ligated, while testicular arteries, cremasteric arteries, lymphatic vessels, and the vas deferens are preserved.

To assess the surgical outcomes, semen samples will be collected after 3-5 days of sexual abstinence preoperatively (at least a week apart, utilizing the second sample) and postoperatively at 3 and 6 months. The differentiation of seminal round cells into leukocytes and spermatogenic cells will be conducted using combined morphological and enzymatic methods. Semen smears will be stained with Papanicolaou stain and examined under light microscopy to identify spermatogenic cells based on nuclear morphological features. A peroxidase (Endtz) test will concurrently be used to differentiate peroxidase-positive leukocytes from peroxidase-negative spermatogenic cells. The spermatogenic cell concentration will be quantified using a Neubauer hemocytometer according to the WHO 2021 manual equation.

Inclusion criteria

• Infertile married males diagnosed with clinical varicocele.
• Age between 20-45 years.
• Patients indicated for varicocelectomy according to standard clinical guidelines.
• Abnormal or suboptimal semen parameters on at least two semen analyses.

Exclusion criteria

• Azoospermic patients (complete absence of sperm in semen).
• History of previous varicocelectomy or scrotal surgery.
• Presence of other known causes of infertility (e.g., genetic abnormalities, obstructive azoospermia).
• Active genital infection or systemic infection affecting semen analysis.
• Use of medications affecting spermatogenesis within the last 3 months (e.g., testosterone, chemotherapy).
• Chronic systemic diseases known to affect fertility (e.g., uncontrolled diabetes, liver failure).
• Severe leukocytospermia as confirmed by peroxidase (Endtz) test exceeding WHO reference limits.
• Pus cell > 1 million/ml by peroxidase.