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Efecto del tratamiento de varicoc= ele sobre el resultado de la fertilidad en el varón infértil

 

Effect of varicoce= le treatment on fertility outcome in infertile males

 

 

= 1

Víctor Andrés Parrales Pincay<= span style=3D'color:black'>

https://orcid.org/0000-0002-6960-8941

 

 

Médico Cirujano, Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad Técnic= a de Manabí

Vparrales9988@utm.edu.ec

= 2

Alfredo Lázaro Marín Pérez

https://orcid.org/0000-0003-3928-260X

 

 

Especialista de Pr= imer y Segundo Grado en Cirugía General, Doctor en Ciencias de la Educación po= r la Universidad de la Habana, Cuba. Profesor Titular de la Universidad Técnic= a de Manabí, Ecuador

Alfredo.marin@utm.edu.ec

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 <= /span>

 <= /span>

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Artículo de Investigación Científica y Tecnológica

Enviado: 08/07/2022

Revisado: 10/08/2022

Aceptado: 05/09/2022

Publicado:05/10/2022   

DOI:      https://doi.org/10.33262/anatomiadigital.v5i4.23= 62   

 

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Cítese:

 

 

 

Parrales Pincay, V. A., & Marín Pérez, A. L. (2022). Efecto del tratamiento de varicocele sobre el resultado de la fertilidad en el varón infértil. Anat= omía Digital, 5(4), 54-66. https://doi.o= rg/10.33262/anatomiadigital.v5i4.2362  

 

 

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La revista es editada por la Editorial Ciencia Digital (Editorial de prestigio registrada en la Cámara Ecuatoriana de Libro con = No de Afiliación 663) www.celibro.org.ec<= span style=3D'font-size:8.0pt;font-family:"Times New Roman",serif;mso-fareast-= font-family: "Times New Roman"'>

 

 

 

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Palabras claves: Varicocele, fertilidad, infertilidad, reproducción masculina.

 

Resumen

Intr= oducción: El varicocele es una dilatación de los plexos pampiniforme ocasionado por la presencia del flujo retrogrado, la incidencia de varicocele en la población masculina clásicamente ha sido descrita cercana al 16%, siendo el 35-45% entre los hombres con infertili= dad. Objetivo: Analizar el efecto que acciona el tratamiento de varicoc= ele en los resultados de la fertilidad en el varón infértil. Metodología:<= /b> Se realizó una búsqueda en idioma inglés y español en las bases Sciencedirec= t, PubMed, Redalyc y Scielo, con los descriptores, Varicocele, Infertilidad Masculina, Tratamiento, Resultados usando el booleano AND encontrando 64 publicaciones y seleccionando 28.  Resultados: El tratamiento más utilizado fue la cirugía laparoscópica en los pacientes con infertilidad y el tratamiento conservador en los casos sin infertilid= ad y sin dolor. Conclusiones: El tratamiento quirúrgico demostró mejora= r la infertilidad en un 80% en el término de 12 meses.

 

 

Keywords:= Varicocele, fertility, infertility, male reproduction<= /o:p>

 

Abstract

Introduction: Varicocele is a dilatation= of the pampiniform plexuses caused by the presence of retrograde flow, the incidence of varicocele in the male population classically has been descr= ibed close to 16%, being 35-45% among men with infertility. Objective: To anal= yze the effect of varicocele treatment on fertility outcomes in infertile men. Methodology: A search was conducted in English and Spanish in the databas= es Sciencedirect, PubMed, Redalyc and Scielo, with the descriptors, Varicoce= le, Male Infertility, Treatment, Results using the Boolean AND finding sixty-= four publications and selecting twenty-eight. Results: The most used treatment= was laparoscopic surgery in patients with infertility and conservative treatm= ent in cases without infertility and without pain. Conclusions: Surgical treatment was shown to improve infertility by 80% within 12 months.<= /o:p>

 

 

 

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Introducción

El varicocele es el aumento de volumen de la vena testicular o espermática int= erna con dilatación palpable de las tributarias proximales de dicho vaso en el cordón espermático, es decir, el plexo pampiniforme. Se le ha señalado como= la causa aislada más común de infertilidad en el varón. El varicocele tiene una frecuencia de un cinco a unos quince porcientos en la población general y d= el veinte al cuarenta porcientos en los hombres infértiles (1).

La Organización Mundial de la Salud (OMS) considera que existe infertilidad masculina cuando hay alteración del espermatograma, principalmente en la calidad seminal, que viene definida por la concentración, motilidad y morfología de los espermatozoides. El varicocele es causal importante de infertilidad masculina, alterando tanto la producción como la calidad de se= men (2) Estas anormali= dades encontradas en el análisis de calidad seminal de los pacientes con varicoce= le se toman en base a la densidad, motilidad y morfología definidos por la OMS= .

La infertilidad pertenece a los inconvenientes de salud pública que están afectando a la sociedad, razón por la cual el Ministerio de Salud Pública lo tiene como prioridad para mejorar la calidad de vida en las parejas inférti= les, gracias a los elevados porcentajes que este ocupa, lo que equivale 10% poblacional en edad reproductiva. Entre sus principales causas se encuentra= el varicocele, entidad presente en el 15 % de la población masculina y diagnosticada en el 40 % de los hombres con infertilidad primaria y en un 7= 5-85 % de aquellos con infertilidad secundaria.

Realizaron un estudio donde se examinaron muestras de semen de 40 pacientes diagnostic= ados de varicocele entre las edades de 15 y 30 años, acorde a los parámetros de = la OMS. Se encontró mejoría en la concentración media de espermatozoides los t= res meses, seis meses y a los 12 meses, pero no fue significativa (p> 0,05).= La puntuación media de morfología de Kruger tampoco fue significativa. Los hallazgos sugieren que, a pesar del aumento en el recuento y la motilidad, observadas en el posoperatorio en los espermatozoides de los pacientes con varicocele, las tasas de morfología permanecen intactas (3)

El varicocele es una de las más grandes razones de infertilidad varonil. El procedimiento quirúrgico del varicocele está indicado en pacientes con infertilidad y varicocele clínico o palpable. 

En dirección al problema se planteó una interrogante que visibiliza ¿Cuáles son los efectos que ocasionan los tratamientos de varicocele por medio de los resultados de la fertilidad en el varón infértil?

El objetivo de esta revisión científica es analizar el efecto que acciona el tratamiento de varicocele en los resultados de la fertilidad en el varón infértil.

Metodología

Se realizó una revisión bibliográfica en Redalyc, Scielo, Pubmed y SciencieDir= ect, empleando los descriptores y términos: “Varicocele”, “Infertilidad masculin= a” “Tratamiento” y “resultados”, utilizando el booleano AND.  Limitado a: menos de 5 años, idioma español y/o inglés y disponibili= dad de los artículos de forma libre. Se encontraron 64 artículos, se revisaron todos los resúmenes se excluyeron 36 por inconsistencias metodológicas, cos= to al descargar y falta de seguimiento. Se utilizaron 28 artículos en esta publicación.

Varicocele

El varicocele, causa identificable más común en la infertilidad masculina, es = la dilatación anormal del plexo venoso pampiniforme en el cordón espermático. = Se presenta en los hombres adultos de forma unilateral en el lado izquierdo en= el 90%, mientras que en un 10% aparece bilateralmente (4).

La afectación es más recurrente del lado izquierdo. Las venas desembocan en la vena espermática interna, en la zona del anillo inguinal interno, esa vena = se coloca por fuera del conducto deferente en el anillo inguinal interno y en = el lado izquierdo desemboca la vena renal, en tanto que el lado derecho drena = en la vena cava.

El varicocele puede ser clasificado según los grados de severidad:<= /span>

·      =    Subclínico: No palpable o visible en reposo o maniobras de Valsalva, pero se demuestra reflujo en el examen de ecografía doppler.

·      =    Varicocele grado I: Palpable pero no visible durante las maniobras de Valsalva.

·      =    Varicocele grado II: Visible y palpable durante las maniobras de Valsalva.

·      =    Varicocele grado III:<= span style=3D'font-size:12.0pt;line-height:115%;font-family:"Times New Roman",se= rif'> Visible y palpable a simple vista.

La disminución del volumen o hipotrofia testiculares, ipsilateral al varicocel= e, se encuentra más frecuentemente asociada a los grandes varicoceles o varicoceles grado 3 (73%), que en medianos varicoceles o varicoceles grado 2 (55%), y pequeños varicoceles o varicoceles grado 1 (49%); Igualmente la disminución del conteo o cantidad espermática es directamente proporcional y significativa al grado de varicocele.

La incidencia del varicocele es de35% a 40% en hombres con infertilidad primar= ia, pero aumenta a 80% en los hombres con infertilidad secundaria, sugiriendo el declive progresivo en la fertilidad masculina. Sin embargo, no todos los varicoceles están relacionados con la infertilidad masculina, y hombres con varicoceles de bajo grado pueden procrear (5).

Un varicocele principalmente se realiza desde las venas que transportan sangre= que sale a partir de los testículos hacia la vena cava. Comúnmente, las válvula= s en estas venas ayudan a que la sangre se mueva en dirección ascendente. Si hay= un problema con estas válvulas (deficiencia o ausencia de ellas), puede produc= irse una acumulación de sangre. Esto provoca que las venas cercanas al testículo= se dilaten, lo cual resulta en un varicocele.

Causas anatómicas que inciden en el varicocele izquierdo siendo mayor que el derec= ho

Las principales causas anatómicas de que la incidencia de varicocele izquierdo = sea mayor al derecho son:

·      =    Recorrido de mayor longitud de la vena espermática izquierda respecto a la derecha, provocando un aumento de presi= ón hidrostática en dicha vena.

·      =    Existencia de condiciones más favorabl= es para el drenaje venoso de la vena espermática derecha, dado que dicho drena= je se realiza con una angulación de 30° a 40° en la vena cava inferior, mientr= as que la vena espermática izquierda drena con un ángulo de 90° en la vena ren= al izquierda.

·      =    Existencia de una menor cantidad o de ausencia total congénita de válvulas ostiales en la vena espermática izquie= rda.

Manejo del Varicocele

La insuficiencia valvular venosa de las venas espermáticas, manifestada por una dilatación del plexo pampiniforme o varicocele, es una causa fundamental de infertilidad que se muestra hasta en el 40% de los varones infértiles a diferencia de una frecuencia del 15% en la población fértil. No obstante, p= ara que el varicocele logre ser considerado como una causa de infertilidad, deb= ería estar referente con alteraciones en el estudio del semen.=

La presencia de estas várices testiculares se ha relacionado con la infertilid= ad masculina; en pacientes con infertilidad primaria la incidencia se encuentra entre un 30 a 50% y en pacientes con infertilidad secundaria hasta en un 80= %, más específicamente, con disminución en el número de espermatozoides, de su movilidad, morfología y capacidad de fecundación (6).

La Infertilidad Masculina

La infertilidad, definida por la OMS como la incapacidad de lograr un embarazo clínico después de 12 meses o más de relaciones sexuales no protegidas, es = un problema que en países desarrollados afecta a un 14% de las parejas. Hasta ahora el abordaje del varón infértil se ha centrado fundamentalmente en el análisis del seminograma (concentración espermática, motilidad y morfología= ).

Sin embargo, cada vez más estudios apuntan a la necesidad de actualizar este abordaje incluyendo nuevos biomarcadores moleculares de infertilidad mascul= ina más específicos y adecuados a la evolución actual tanto de la infertilidad masculina propiamente dicha como de las técnicas de reproducción asistida.<= o:p>

Actualmente la infertilidad es una enfermedad que se estima que afecta entre el 15-20% = de las parejas en edad reproductiva. Más de 45 millones de parejas en todo el mundo se ven afectadas por la infertilidad, y más del 40% de estos casos incluyen algún componente de la infertilidad masculina. Se estima que, a es= cala mundial, hasta el 12% de los hombres (> 30 millones) tendrán problemas de fertilidad durante su vida (7).

Se han identificado múltiples factores de riesgo de infertilidad masculina com= o la presencia de algunas enfermedades endocrinas, genéticas, urológicas, así co= mo el envejecimiento, exposición a sustancias y hábitos tóxicos, entre otros. Estos factores producen trastornos en el eyaculado que se evidencia en alte= raciones del espermograma, complementario imprescindible para el diagnóstico de la infertilidad masculina (8)

Los componentes de peligro que están afectando la fertilidad en el ser humano s= on distintos y, además de las alteraciones genéticas conocidas o no, van a par= tir de la disfunción eréctil apresurada frecuentemente por el uso de la testosterona que puede llegar a perjudicar la capacidad del testículo para construir espermatozoides, los estilos de vida, la utilización de determina= dos medicamentos, el consumo de drogas, el tabaquismo que perjudica prácticamen= te la morfología y la movilidad de los espermatozoides; hasta la obesidad, las patologías infecciosas como las de transmisión sexual, entre otros.

Resultados

Manejo de varicocele

Actualmente, se conoce que alrededor del 15% de la población masculina general desarroll= ará algún grado de varicocele, con una incidencia menor del 1% en niños de 2-10 años y con un aumento a 14% en adolescentes de 15-19 años, siendo la infert= ilidad y el dolor testicular asociado las causas de consulta más frecuentes. Aproximadamente, el 78-93% de los hombres presentará varicocele unilateral izquierdo, 1-7% de los casos se presentará como varicocele unilateral derec= ho, y de manera bilateral en el 2-20% de los casos (9) (10)

 

 

Manejo conservador

El manejo inicial del varicocele deber ser conservador en compañía de un perio= do de observación, ya que un estudio demostró que el 45% de los pacientes analizados presentaban una alteración en el espermograma, de los cuales, el= 50% tuvieron una recuperación espontánea en los parámetros seminales, razón por= la cual se recomienda este periodo de gracia (15,5 meses); sin embargo, el 22,= 5% de los pacientes persistieron con alteraciones en el espermograma, a pesar = de presentar un varicocele indoloro y un volumen testicular normal (11)<= !--[if supportFields]> (12) (13)

Las guías han reservado el manejo quirúrgico para los pacientes infértiles con = un espermograma anormal, sin embargo, la Sociedad Americana de Medicina Reproductiva, junto con la Sociedad de Reproducción Masculina y Urología, presentaron actualizaciones de las guías donde agregan que la intervención quirúrgica también es aceptada en aquellos pacientes que presentan dolor escrotal persistente que no mejora con las medidas conservadoras sin import= ar el estado de fertilidad (14) (25)

El tratamiento del varicocele ha demostrado un impacto beneficioso sobre la fertilidad, de tal forma que debería ser considerado el primer tratamiento = para tomar en consideración al evaluar parejas infértiles. La varicocelectomía l= ogra mejorar la movilidad de los espermatozoides en más del 50% de los casos, con tasas de embarazos espontáneos de casi 40% en individuos con oligozoospermi= a. Otras investigaciones han reportado incluso que tras la cirugía de varicoce= le cerca del 55% de los varones con azoospermia y el 69% de varones con astenozoospermia han presentado espermatozoides móviles (15)

Indicaciones para el tratamiento del varicocele en infertilidad masculina:

 Debe siempre ser considerado en todos los pacientes bajo las siguientes condiciones:

·      =    Varicocele palpable o visible en el escroto.

·      =    Existencia de infertilidad de pareja.<= o:p>

·      =    La fertilidad femenina es normal o la causa de infertilidad es potencialmente tratable.

·      =    Hallazgos en el espermatograma de cualquier anormalidad.

·      =    No está indicada la realización de varicocelectomía en paciente con parámetros normales en el espermatograma, o varicoceles subclínicos (16) (26)

Tratamiento del varicocele:

 El tratamiento para el varicocele puede = ser quirúrgico o por embolización. Para decidir qué tipo de acceso se va a real= izar es necesario tener presente los tres tipos de vías de formación del varicoc= ele:

·      =    Fracaso de la vena espermática interna= .

·      =    Hiperpresión de la vena iliaca primiti= va.

·      =    Anomalías de los plexos venosos. 

Para muchos autores, el fracaso de la vena espermática interna es el más patológ= ico y agresivo.

Los hombres con varicoceles clínicamente palpables y los parámetros seminales normales pueden estar en riesgo de futuro disfunción testicular. Witt y Lipshultz demostraron que varicoceles son capaces de causar la pérdida de la fertilidad progresiva. En su análisis retrospectivo, señalaron que los varicoceles fueron identificados como la causa de la infertilidad en el 69%= de los hombres con infertilidad secundaria en comparación con el 50% de los hombres con infertilidad primaria, lo que sugiere que los varicoceles son lesiones progresivas que ocasionan la pérdida de la fertilidad previamente establecido.

Tratamiento quirúrgico

El tratamiento más utilizado para el varicocele es el quirúrgico: Cuando se tr= ata de un paciente debe ser informado que la mayoría de las guías de tratamiento internacionales no recomiendan el tratamiento en dicho caso y que la mejoría con el tratamiento quirúrgico suele ser evidente, pero acostumbra a persist= ir algún tipo de molestia residual que se mantiene en el tiempo (19) (23)

Los datos de los que disponemos actualmente apoyan la hipótesis de que en algun= os hombres la presencia del varicocele produce un daño testicular progresivo q= ue suele iniciarse desde la adolescencia, y en consecuencia la reducción en la fertilidad, aunque los mecanismos exactos de esta asociación todavía están = por aclararse. La suma por una parte de la disminución en los parámetros semina= les de concentración, movilidad y morfología de los espermatozoides y el daño a nivel molecular en el ADN producidos por el aumento de estrés oxidativo par= ecen ser factores importantes.

El tratamiento quirúrgico elimina en más del 90% el varicocele. Los resultados= de la embolización percutánea son variables y dependen de la experiencia y habilidad del radiólogo intervencionista. Algunos reportes refieren que la calidad del esperma mejora en su mayoría con el tratamiento quirúrgico del varicocele (17)

Las complicaciones con la varicocelectomía son infrecuentes y usualmente leves. Entre ellas están: Infección, hidrocele, persistencia o recurrencia del varicocele, y muy rara, la atrofia testicular. La incisión inguinal puede causar alteración de la sensibilidad escrotal y dolor prolongado.

En EE. UU. se encuentra en el 25% de adultos con una media de 25 años. Se pres= entó en un 20% a 40% de los hombres infértiles, y en el 15% de población (20)<= !--[if supportFields]>.

Discusión=

En general, los estudios más representativos sugieren que la cirugía tiene una influencia beneficiosa en la fertilidad. Esto ha justificado que, desde el principio de la década de los 50, la ligadura de la vena espermática haya ocupado un lugar preferente en el arsenal terapéutico ofrecido por los uról= ogos para mejorar la fertilidad en los casos de varicocele. De hecho, el tratami= ento del varicocele ha representado un oasis de esperanza para los pacientes, po= r lo demás, desolado paisaje de los tratamientos médicos ineficaces para tratar = la fertilidad masculina (18) (22)

En pacientes afectos de varicocele se puede observar una detención de la maduración con déficits en la unión de las espermátidas produciendo secundariamente alteraciones en la espermatogénesis. Tras el tratamiento, se objetiva una restauración de la correcta maduración de las espermátidas (17)<= !--[if supportFields]> (24)

El 79 % de las desembocaduras de la vena espermática izquierda es en la vena r= enal izquierda. La vena espermática derecha desemboca oblicuamente en la cava in= ferior en el 78 % de las veces. El resto tiene diferentes porcientos de anomalías. Esto es importante conocerlo porque podría explicar las recidivas del varicocele (21) (27) (28)

Conclusión

El   varicocele   es   una   de   las   principales causas    de    infertilidad    masculina, presentándose en un gran porcentaje de los hombres con algún grado de infertilidad primaria y secundaria.

Si bien el proceso fisiopatológico por el cual el testículo desarrolla varicoc= ele es claro, los mecanismos por los cuales el varicocele produce infertilidad = aún son inciertos.

La cirugía está recomendada en casos con infertilidad y/o dolor.

La ligadura laparoscópica de las venas espermática es considerada la de elecci= ón para el tratamiento del varicocele en hombres infértiles debido a que produ= ce una normalidad de la motilidad y la morfología de los espermatozoides.

Referencias B= ibliográficas=

= x

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Owen = R, McCormick B, Figler B, Coward R. A review of varicocele repair for pain. Translational Andrology and Urology. [Online].; 2022. Available from: <= /span>.

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Min J, Don S. Varicocele: Pediatric Urological Perspectives.The World Journal = of Men´s Health. [Online].; 2022. Available from: https://www.ncbi.nlm.nih.gov/= pmc/articles/PMC5924953/.

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= 3Deditorial1.png<= ![endif]>x

 =

 

 

 

 

 

El artículo que se publica es de exclusiva responsabilidad de los autores y no necesariamente reflejan el pensamiento de la Revista Anatomía Digital.

 

3Deditorial1.png

 

 

 

El artículo queda en propiedad de la revista y, por tanto, su publicación parc= ial y/o total en otro medio tiene que ser autorizado por el director de la R= evista Anatomía Digital.

 

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Revista Información Científica, = vol. 98, núm. 2, pp. 283-293, 20192019https://www.redalyc.org/journal/5517/551760346015/html/21Cas18DocumentFromInternetSite{5CC0B345-2307-471F-B3B= A-67AB6D8E1052}Casamayor, M.TRATAMIENTO DEL VARICOC= ELE EN EL VARÓN INFÉRTIL: RESULTADOS SOBRE LA CALIDAD SEMINAL Y LA FERTIL= IDAD 201823= Nol17DocumentFromInternet= Site{93A70165-1710-4B12-9AD1-E32716127CB1}<= b:Author>Noles, M.VARICOCELE2017http://dspace.ucuenca.edu.ec/bitstream/123456789/31908/1/TESIS.pdf<= /b:URL>22Vel17= DocumentFromInternetSite{FF898CF2-7DBA= -4655-8F59-B7FD95E03912}Vela I, C= aravia I, Lourou E.Importancia del varicocele derecho. Revista Cubana de Urología. 2017http://www.revurologia.sld.cu/inde= x.php/rcu/issue/view/1426Rui181DocumentFromInternetSite{9E52948F-A396-4D6C-8011-B910BF4EF39E}Ruiz E, Pasqualini T, Alonso G, Moldes J, Puigdevall JC, Mo= randi A, et al.Var= icocele en la pubertad y adolescencia: una nueva perspectiva para el pediat= ra. Arch. Argent. 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=                                       Biotecnología                           Página 54 | 1

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