The World Health Organization has developed the manual on standardized examination, diagnosis and management of man infertile (2000. Among the variety of the causes of male infertility varicocele is rather great in development of infertility. The questions of diagnosis and treatment of male infertility are the important problems in the modern andrology. Taking into e above-stated, we have defined the purpose of research as The efforts to improve the results of treatment of the patients with male infertility associated with subclinical varicocele by perfection of the therapeutic-diagnostic algorithm at the given pathology, in particular.
Material and methods of researches . There were analyzed the results of treatment of 78 patients admitted with the symptoms of male infertility to the stationary treatment in the First Clinical Hospital in Tashkent-city at the clinical base of the Chair of operative urology and nephrology of Tashkent Medical Institute of Postgraduate Education, at who were diagnosed subclinical varicocele after examination.
The age of the patients fluctuated from 19 till 27 years. Duration of disease to the moment of the admission was 19.4.3.2 months.
The main instrumental method of diagnosis of subclinical varicocele was colour ultrasonic dopplerography (CUSDG). During investigation the measurement of the vein maximal diameter, the sum of varicose vein plexuses , blood flow velocity changes in Valsalva test were in the focus of attention. Using the technique manual compression of C. Trombett modification of E.B.Mazo we defined hemodynamic types of varicocele by Collseat. Depending on a type of wenaus reflux there was defined renospermatic (type1), ileospermatic (type2), and mixed (type3), types.
The therapeutic algorithm was determined in relation to the CUSDG results. During identification of type 1 varicocele the ligation of spermatic veins as carried out by lvanisevich/ At minimal percent of changes in the sperm analyses and in hemodynamic type 2 we abstained from operative intervention. These patients were under dynamic supervision with periodic performance of the analysis of sperm. In marked changes in spermogram there was performed ligation of the iliac collaterals, formation of testiculo-epigastral anastomoses.
At presence in the patient of hemodynamic type 3 vaicocele the first was the performance of operation by lvansevich forliquidation of renaspermatic reflux. Taking into account an opportunity of domination of ileospermatic reflux in the postoperative period there was performed control sperm analysis. At normalization of the ejaculate analysis the patients were under dynamic supervision. At preservation of sperm that indicated about prevalence of ileospermatic reflux there was carried out ligation of ileocallaterals or formation of testiculo-epigastral anastomosis.
Results
The performance of Cusdg allowed to diagnose hemodynamic type 1 of reflux in 67 (85.9 %) patients, the second type in 7 (8.9%) patients, and type 3 in (5,2 %) patients. The maximal diameter of veins was 3,5mm, the sum of varicose vein plexuses 3,0 mm, the blood flow speed at performance of Valsalva test was 12,4 cm/sec.
The analysis of spermograms revealed that the quantity of spermatozoons fluctuated from20 up to 108 mln/ml (on the average 55,4 6,1), the quantity of active movable – 0-57% (31,9 9,4,0) weakly movable -0-40% (20,3 3,9), immovable- 21-100% ( 47,8 4,5), alive -20-66% (46,8 4,1) dead -34,80% (53,2 4,1). It is necessary to note, that the greatest changes in the spermogram were found at presensce of the first hemodynamic type.
At type 1 in 67 cases the operation of lvanisevich was performed. IN the patients with the 2d type in 2 cases there was carried uot ligation of iliac collaterals and 2 cases there was formed testiculo- epigastral anastomosis, in the rest 3patients the change in the analyses of spermogram were not significant and they were taken on monitoring. At type 3 at the first stage all patients were performed apernation of lvanasevich. After operation only in one case there were no changes in spermogram, this patient was performed ligation of the iliac collaterals.
The study of spermograms of the patients in the postoperative period shoved that in 45 (57,7%) patients there was found normalizations of the partameters during the period from 2 to 5 months.
Conclusions
1. The color ultrasound dopplerography seams to be the most informative method of diagnosis of the subclinical varicocele which allows identification of the hemodynamic types of the reflux.
2. The analysis spermogram in subclinical varicocele allowed to reveal on the basis of the results of CUSDG that the most marked changes were noted in renospermatic type of the reflux.
3. The use of the therapeutic-diagnosis algorithm developed by us for male infertility associated with subclinical varicocele allows restoration of the reproductive functioning 57,7 % of cases.
