Orientador: Adriana Orcesi Pedro / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-12T09:22:16Z (GMT). No. of bitstreams: 1 Silveira-Barbetti_CarolinaFernanda_D.pdf: 1494162 bytes, checksum: 743c1f97b1d23cbeab92921d0c8d7688 (MD5) Previous issue date: 2008 / Resumo: Introdução: A infertilidade masculina pode acometer entre 30% e 40% dos casais inférteis. Dentre esses fatores está a varicocele, que afeta 15% da população em geral e que nesses homens inférteis chega a 30%-40%, podendo estar relacionada com alterações na amostra seminal e conseqüente fertilidade. Objetivo: Comparar amostras seminais de homens férteis sem varicocele com homens inférteis com varicocele quanto a(os) parâmetros macroscópicos e microscópicos; recuperação espermática após swim-up; tipos de marcação dos receptores de D-manose em espermatozóides com acrossoma íntegro e ocorrência da reação acrossomal independente da ligação de D-manose em dois tempos. Sujeitos e Métodos: foi realizado um estudo corte transversal comparando o grupo de pacientes com queixa de infertilidade e varicocele (N=30) com o de homens férteis e sem varicocele (N=30) através do espermograma, processamento espermático e testes funcionais nas amostras recém-ejaculadas (zero hora) e após processamento (uma hora). Os dados foram analisados pelos testes exato de Fisher, Mann-Whitney, quiquadrado e análises repetidas de Friedman. Resultados: O grupo com varicocele apresentou alterações significativas em relação ao grupo-controle na análise seminal quanto à cor (p<0,01), viscosidade aumentada (p<0,01), menor concentração espermática (p<0,01), menor motilidade (A+B) (p<0,01), menor vitalidade (p<0,01), menor inchaço hiposmótico (p<0,01) e maior alteração na morfologia estrita de Kruger (p<0,01). Após capacitação espermática pela técnica de swim-up, o grupo com varicocele apresentou menor concentração espermática (p<0,01) e menor porcentagem de espermatozóides com expressões dos receptores de Dmanose e não reagidos acrossomicamente, independente do tempo (p<0,01). Não houve diferença significativa das amostras em cada grupo quando avaliadas separadamente, entre os dois momentos independentes do status acrossomal e da presença da expressão dos receptores para D-manose. Os quatro padrões de marcação com D-manose e acrossoma íntegro mais observados no grupo com varicocele foram cabeça manchada (21,1%), peça intermediária preenchida (13,1%), região equatorial preenchida (10,6%) e cabeça preenchida (9,8%). Conclusão: espermatozóides de homens com varicocele apresentaram alterações qualitativas, quantitativas e funcionais, podendo comprometer a fertilização espontânea. / Abstract: Introduction: Male infertility may affect 30% to 40% of infertile couples. Among this factors, varicocele affects 15% of the general population and may reach 30%-40% of infertile men. The varicocele to be able to exhibit disturbance in the semen specimens and fertility result.Objectives: To compare, at two time points, semen samples from fertile men and infertile men with varicocele with respect to macroscopic and microscopic parameters, sperm recovery after swim-up, patterns of labeling of D-mannose-ligand receptor in spermatozoids with intact acrosome and the occurrence of acrosomal reaction irrespective of the expression of D-mannose-binding sites. Subjects and methods: A crosssectional study was carried out to compare a group of patients with complaints of infertility and varicocele (n=30) and a control group of fertile men without varicocele (n=30) by performing semen analysis, sperm processing and functional tests carried out in recently ejaculated samples (time zero) and following processing (one hour). Statical analysis was performed through Fisher's exact test, chisquare test, Mann-Whitney test and Friedman repeated analysis of variance. Results: Significant alterations were found in the group of men with varicocele compared to the control group with respect to color (p<0.01), increased viscosity (p<0.01), lower sperm concentration (p<0.01), lower motility (A+B) (p<0.01), lower vitality (p<0.01), lower rates of hypoosmotic swelling (p<0.01), greater alterations in morphology according to Kruger's strict criteria (p<0.01). After performing swinup lower sperm concentration (p<0.01) and lower percentage of sperm cells expressing D-mannose binding sites, together with intact acrosomal status irrespective of time (p<0.01) in infertile men with varicocele. There was no statistically significant difference between the samples of each group when evaluated separately at the two time points, irrespective of acrosomal status and of D-mannose-ligand receptor expression. The four patterns of labeling of Dmannose binding sites and intact acrosome most observed in the varicocele group were: spotty pattern on the head (21.1%), uniform pattern on the mid-piece (13.1%), uniform pattern on the equatorial region (10.6%) and uniform pattern on the head (9.8%). Conclusions: Sperm from men with varicocele have qualitative, quantitative and functional abnormalities that may affect spontaneous fertilization. / Doutorado / Ciencias Biomedicas / Tocoginecologia

No description available.

Η κιρσοκήλη είναι η κιρσοειδής ανεύρεση του οσχεϊκού τμήματος των φλεβών του σπερματικού τόνου (ελικοειδούς πλέγματος). Η κιρσοκήλη έχει αναγνωρισθεί ως μια από τις πιο κοινές αιτίες της ανδρικής υπογονιμότητας. Η συχνότητα στο γενικό πληθυσμό είναι περίπου 15%. Περίπου το 30% - 50% των ανδρών που πάσχει από πρωτοπαθή υπογονιμότητα εμφανίζει κιρσοκήλη. Η κιρσοκήλη είναι περισσότερο συνηθισμένη στην αριστερή πλευρά. Επίσης είναι δυνατόν να εμφανιστεί νωρίς στην ήβη, καθώς και περιστασιακά στα αγόρια που βρίσκονται σε προεφηβική ηλικία. Στα παιδιά η συχνότητα εμφάνισής της θεωρούνταν μικρή, αλλά σε πρόσφατες μελέτες διαπιστώθηκε η ύπαρξή της στο 6% των παιδιών ηλικίας 10 ετών, ενώ σε εφήβους το ποσοστό αυτό ανήλθε στο 16%. Πολύ σπάνια εμφανίζεται πριν από την ηλικία των 7-8 ετών. Παρόλο όμως που η κιρσοκήλη αποτελεί μία τόσο συχνή «πάθηση» στους υπογόνιμους άνδρες και μία συχνή «ανατομική ιδιομορφία» στον γενικό πληθυσμό, η αιτιολογία της παραμένει ασαφής. Παλαιότερες θεωρίες σε σχέση με το μήκος των φλεβών, φαινόμενα «συμπίεσης» κ.α. δεν επαρκούν να εξηγήσουν την τόσο συχνή δημιουργία των κιρσοειδών φλεβών, ούτε την ετερογενή επίδραση που έχουν στη λειτουργία του σπερματικού επιθηλίου. Ένα εξάλλου σημαντικό ερώτημα παραμένει πως είναι δυνατόν η ετερόπλευρη κιρσοκήλη να επηρεάζει τη λειτουργία και των δύο όρχεων! Έτσι τα τελευταία χρόνια διαφαίνεται η ανάγκη ανάπτυξης και επιβεβαίωσης κάποιου βιολογικού μηχανισμού που πιθανώς βρίσκεται πίσω από την ανάπτυξη κιρσοκήλης σε ένα μεγάλο κομμάτι του ανδρικού πληθυσμού. Πρόσφατες μελέτες υποστηρίζουν πως η ανάπτυξη κιρσοειδών φλεβών έχει έναν κληρονομικό χαρακτήρα, ειδικά στους πρώτους βαθμούς συγγένειας. Έρευνες σε περιπτώσεις χρόνιας φλεβικής ανεπάρκειας σε κιρσούς κάτω άκρων, υποδηλώνουν ως πιθανή αιτία την κληρονομική αδυναμία-λέπτυνση του αγγειακού τοιχώματος και δυσλειτουργία του ενδοθηλίου, καθώς καταδεικνύονται από μία παρεκκλίνουσα έκφραση της Ενδοθηλίνης-1 (ΕΤ-1, Endothelin-1) και των υποδοχέων της ΕΤΑ και ΕΤΒ (Endothelin Receptors A, B). Η ενδοθηλιακή δυσλειτουργία και η απρόσφορη παραγωγή της ΕΤ-1 ή των υποδοχέων μπορεί να εμπλέκονται στη δημιουργία νέο-ενδοθηλίου και στη διαστολή των φλεβών οδηγώντας στην ανάπτυξη κιρσοειδών φλεβών. Σε μελέτες κιρσών κάτω άκρων έχει αναδειχθεί ως σημαντικό αίτιο η ελαττωμένη έκφραση των υποδοχέων ΕΤΒ στο τοίχωμα των κιρσοειδών φλεβών, το οποίο οδηγεί σε μειωμένη συσταλτική επίδραση της Ενδοθηλίνης-1. Μία αντίστοιχη δυσλειτουργία θα ήταν αναμενόμενη και στην κιρσοκήλη, στα πλαίσια της γενικότερης βιολογικής συμπεριφοράς των φλεβών που υπόκεινται σε κιρσοειδή διάταση. Ωστόσο τα υπάρχοντα δεδομένα στην σύγχρονη βιβλιογραφία όσον αφορά στους κιρσούς σπερματικών φλεβών είναι υπερβολικά πτωχά. Μέχρι και την έναρξη αυτής της μελέτης μία μόνο μελέτη αναφερόταν σε πιθανή δυσλειτουργία του ενδοθηλίου των σπερματικών φλεβών. Ως εκ τούτο, αναπτύξαμε ως βάση αυτής της μελέτης την υπόθεση εργασίας ότι: η ανάπτυξη κιρσοειδών σπερματικών φλεβών οφείλεται όχι σε «εξωτερικά» αίτια όπως συμπίεση κλπ. αλλά σε ενδογενή βλάβη στην λειτουργία του ενδοθηλίου και συγκεκριμένα σε ενδογενή ελάττωση της έκφρασης της ενδοθηλίνης ή/και των υποδοχέων των σπερματικών φλεβών. Για να ελεγχθεί λοιπόν πειραματικά η υπόθεση εργασίας, οργανώθηκε η παρούσα προοπτική μελέτη ανοσοϊστοχημικού προσδιορισμού της ενδοθηλίνης και των υποδοχέων της σε δείγμα κιρσοειδών σπερματικών φλεβών από ασθενείς που υπεβλήθησαν σε χειρουργική αποκατάσταση κιρσοκήλης λόγω υπογονιμότητας. Η σύγκριση με φυσιολογικές φλέβες έγινε με χρήση φυσιολογικού υλικού από τον αντίστοιχο ασθενή ώστε κάθε ασθενής να είναι ταυτόχρονα και μάρτυρας. Επιπλέον μελετήθηκαν οι μορφολογικές αλλοιώσεις των κιρσοειδών καθώς και ένα σημαντικό μέλος του σηματοδοτικού μονοπατιού της ενδοθηλίνης, η ERK1/2 MAP Κινάση, η οποία σχετίζεται με την συστολή των λείων μυϊκών κυττάρων των αγγείων αλλά και με τη ρυθμιστική δράση στον πολλαπλασιασμό, διαφοροποίηση, μετανάστευση των λείων μυϊκών κυττάρων, κοινά ευρήματα στην ανάπτυξη κιρσοειδών φλεβών. Τέλος, σε μία προσπάθεια διερεύνησης της επίδρασης της παραμέτρου του χρόνου στην επίδραση της ενδοθηλιακής δυσλειτουργίας, χρησιμοποιήθηκε υλικό από παιδιά που είχαν υποβληθεί σε επέμβαση κιρσοκήλης. / Varicocele is the pathological finding of varicose veins at the scrotal portion of the spermatic cord (pampiniform plexus) and occurs more selectively on the left side. Varicocele has been recognized as one of the most common causes of male infertility. The frequency in the general population is approximately 15%. Almost 30% to 50% of men who suffer from primary infertility display varicocele. It is also possible to be discovered in early puberty and occasionally in prepubertal boys. In children the frequency of varicocele is considered to be rare but recent studies have shown its presence in 6% of children aged 10 years, while in adolescents this figure rises up to 16%. Before the age of 7-8 years it occurs very rarely. Although varicocele is such a common “disease” in subfertile men and a common “anatomic entity” in the general population, its etiology remains unclear. Previous theories concerning the length of the veins, “compression” phenomena etc. are insufficient to explain the frequency of varicose veins and the heterogeneous effect they may have on the seminiferous epithelium dysfunction. An even more difficult question is how the unilateral varicocele can affect the function of both testicles! Therefore, confirmation of a biological mechanism that probably lies behind the development of varicocele in a large part of the male population seems necessary nowadays. Recent studies suggest that the development of varicoce veins has a hereditary character, especially in first degree relatives. Research in cases of chronic venous insufficiency in lower limbs varicose veins implies the hereditary failure - thinning of the vessel wall and endothelial dysfunction as a cause for varicosity. This is often attributed to aberrant expression of endothelin-1 (ΕΤ-1) and its receptors ETA and ETB (endothelin receptors A, B). The endothelial dysfunction and the inappropriate production of ET-1 or its receptors may be involved in vein wall remodeling and the dilation of veins, leading to the development of varicose veins. In studies concerning varicose veins of the lower limbs decreased expression of ETB receptors in the varicose vein wall and a reduced contractile effect of endothelin-1, have emerged as an important mechanism of varicose veins. A similar dysfunction would be expected in the varicocele setting, as part of the broader biological behavior of veins which are subjected to varicose dilatation. However, the data available in contemporary bibliography regarding the varicose spermatic veins are extremely poor. Until the beginning of this study only one study referring to a possible dysfunction of the endothelium of the spermatic veins was available. Therefore, we developed a working hypothesis that the development of the varicose spermatic veins is not due to ‘’external’’ causes such as compression, etc. but due to endogenous damage to the endothelial function and specifically in reduction of endogenous endothelin and/or its receptors at the spermatic vein wall level. In order to test this hypothesis in an experimental setting we organized this prospective study of the immunohistochemical detection of endothelin-1 and its receptors in varicose veins specimens from infertile patients undergoing surgical correction of varicocele. Normal subcutaneous veins were harvested from each patient at the time of surgery and used as control specimens, so that each patient should serve as its own control. Furthermore, we studied the morphological alterations of varicose veins as well as a substantial part of the endothelin - ERK1/2 MAP kinase signaling pathway, which is related to the contraction as well as with the regulation of proliferation, differentiation and migration of smooth muscle cells at the vein wall. Finally, we also included surgical specimens from children who had undergone surgery for varicocele correction at an early age in an effort to investigate the effect of time parameters on endothelial dysfunction.

INTRODUÇÃO: Infertilidade atinge aproximadamente 15% dos casais em idade reprodutiva e afeta de maneira profunda a vida dessas pessoas. Dentre as causas identificáveis de infertilidade masculina, a varicocele é a mais frequente e acomete cerca de 40% dos homens inférteis ou subférteis. Um dos maiores desafios na abordagem cirúrgica da varicocele é a identificação de indivíduos que apresentarão maior benefício com o tratamento, uma vez que muitos pacientes não apresentam melhora da análise seminal. OBJETIVOS: Identificar um padrão histológico testicular como prognóstico da melhora da capacidade reprodutiva em pacientes submetidos à varicocelectomia microcirúrgica. METODOLOGIA: Estudo retrospectivo composto pela análise de 60 biópsias testiculares bilaterais de homens inférteis atendidos em clínica especializada de fertilidade masculina, entre os anos de 2006 e 2014. Como critérios de inclusão foram considerados homens com diagnóstico de varicocele clínica e subclínica entre 19 e 50 anos de idade com resultados de análise histopatológica testicular. Os sujeitos de pesquisa foram divididos em dois grupos. Grupo 1: homens com diagnóstico de varicocele subclínica (n = 20). Grupo 2: homens com diagnóstico de varicocele clínica (n =40). Foram excluídos do estudo homens com diagnóstico de criptorquidia, azoospermia obstrutiva e não-obstrutiva, usuários de drogas e anabolizantes, além de pacientes portadores de doenças sexualmente transmissíveis e de neoplasias no trato geniturinário. Os participantes foram submetidos ao exame físico urológico com a avaliação do volume testicular por meio de ultrassonografia da bolsa escrotal com Doppler-Colorido. O diagnóstico da varicocele foi realizado por meio da palpação cuidadosa do plexo pampiniforme com o paciente em posição ortostática. A manobra de Valsava foi utilizada para a classificação clínica do grau de varicocele. Para a determinação de um padrão histológico capaz de predizer a melhora da capacidade reprodutiva, foram criados valores de corte que associam os scores de Johnsen, os índices de Copenhagen e o volume testicular à melhora dos parâmetros seminais. RESULTADOS: No grupo 1, para a melhora da concentração espermática o score de Johnsen deve ser superior a 8,2 (lado esquerdo) e o volume testicular acima de 12,8 mL (lado direito). Adicionalmente, para a avaliação da motilidade total de espermatozoides os scores de Johnsen devem ser superiores a 8,2 (bilateral) e o dígito II de Copenhagen inferior a 2,5 em ambos os testículos. Todavia, para a motilidade progressiva de espermatozoides o score de Johnsen deve ultrapassar a 9,1 (bilateral) e na avaliação da morfologia espermática, este deve se apresentar acima de 7,9 e com volume testicular acima de 13,6 mL (lado direito). Quanto aos valores de corte obtidos no grupo 2, para a concentração de espermatozoides, os scores de Johnsen devem ser superiores a 5,5 com volume testicular acima de 11,5 mL em ambos os testículos. Finalmente, quanto à motilidade espermática total e progressiva, o dígito III do índice de Copenhagen deve ser inferior a 1,5 (lado direito). CONCLUSÃO: Valores prognósticos da melhora da capacidade reprodutiva obtidos por meio de biópsia testicular podem auxiliar com eficácia no prognóstico e na avaliação dos pacientes candidatos à correção microcirúrgica da varicocele / BACKGROUND: Infertility affects approximately 15% of couples in reproductive age and profoundly changes the lives of these people. Among the identifiable causes of male infertility, varicocele is the most common and affects about 40% of infertile or subfertile men. One of the challenges in the surgical approach is the identification of individuals who will present benefits with the treatment, since many patients do not show improvement of semen analysis. OBJECTIVE: To identify a testicular histological pattern as prognostic value of improved reproductive capacity in patients submitted to microsurgical correction of varicocele. METHODS: we retrospectively analyzed bilateral testicular biopsies of 60 men attending specialized clinic of male fertility between the years 2006 and 2014. As inclusion criteria were considered men diagnosed with clinical and subclinical varicoceles between 19 and 50 years old with results of testicular histopathology and seminal analysis. The patients were divided into two groups. Group 1: Men diagnosed with subclinical varicocele (n = 20). Group 2: men diagnosed with clinical varicocele (n = 40). Men diagnosed with cryptorchidism, obstructive and non-obstructive azoospermia, users of drugs and anabolic steroids were excluded of the study. All Participants were submitted to urological physical examination with the evaluation of testicular volume by ultrasonography of the scrotum with Color Doppler. The diagnosis of varicocele was performed by careful palpation of pampiniform plexus with the patient in standing position. The Valsalva maneuver was used to classify the grade of varicocele. The determination of a testicular histological pattern as prognostic value of the improved reproductive capacity was performed by the creation of cut-off values that associate Johnsen scores, Copenhagen indices and testicular volume to improvement in semen parameters. RESULTS: In Group 1, for improvement of sperm concentration, the Johnsen score must be greater than 8.2 (in the left testicle) and testicular volume must be greater than 12.8 mL (in the right testicle). Concerning evaluation of sperm total motility, the Johnsen score must be greater than 8.2 (bilateral) and digit II of Copenhagen indices must be less than 2.5 (bilateral). However, for sperm progressive motility, the Johnsen score must exceed 9.1 (bilateral) and evaluation of sperm morphology must be greater than 7.9 with right testicular volume greater than 13.6 mL. In Group 2, the cut-offs values for sperm concentration indicates that Johnsen scores must be greater than 5.5 with testicular volume greater than 11.5 mL in both testicles. Finally, regarding the sperm total and progressive motility, the digit III of Copenhagen indice must be less than 1.5 (in the right testicle). CONCLUSION: Prognostic values of improved reproductive capacity obtained from testicular biopsy can assist effectively in the prognosis and evaluation of patients candidates for microsurgical correction

INTRODUÇÃO: Infertilidade atinge aproximadamente 15% dos casais em idade reprodutiva e afeta de maneira profunda a vida dessas pessoas. Dentre as causas identificáveis de infertilidade masculina, a varicocele é a mais frequente e acomete cerca de 40% dos homens inférteis ou subférteis. Um dos maiores desafios na abordagem cirúrgica da varicocele é a identificação de indivíduos que apresentarão maior benefício com o tratamento, uma vez que muitos pacientes não apresentam melhora da análise seminal. OBJETIVOS: Identificar um padrão histológico testicular como prognóstico da melhora da capacidade reprodutiva em pacientes submetidos à varicocelectomia microcirúrgica. METODOLOGIA: Estudo retrospectivo composto pela análise de 60 biópsias testiculares bilaterais de homens inférteis atendidos em clínica especializada de fertilidade masculina, entre os anos de 2006 e 2014. Como critérios de inclusão foram considerados homens com diagnóstico de varicocele clínica e subclínica entre 19 e 50 anos de idade com resultados de análise histopatológica testicular. Os sujeitos de pesquisa foram divididos em dois grupos. Grupo 1: homens com diagnóstico de varicocele subclínica (n = 20). Grupo 2: homens com diagnóstico de varicocele clínica (n =40). Foram excluídos do estudo homens com diagnóstico de criptorquidia, azoospermia obstrutiva e não-obstrutiva, usuários de drogas e anabolizantes, além de pacientes portadores de doenças sexualmente transmissíveis e de neoplasias no trato geniturinário. Os participantes foram submetidos ao exame físico urológico com a avaliação do volume testicular por meio de ultrassonografia da bolsa escrotal com Doppler-Colorido. O diagnóstico da varicocele foi realizado por meio da palpação cuidadosa do plexo pampiniforme com o paciente em posição ortostática. A manobra de Valsava foi utilizada para a classificação clínica do grau de varicocele. Para a determinação de um padrão histológico capaz de predizer a melhora da capacidade reprodutiva, foram criados valores de corte que associam os scores de Johnsen, os índices de Copenhagen e o volume testicular à melhora dos parâmetros seminais. RESULTADOS: No grupo 1, para a melhora da concentração espermática o score de Johnsen deve ser superior a 8,2 (lado esquerdo) e o volume testicular acima de 12,8 mL (lado direito). Adicionalmente, para a avaliação da motilidade total de espermatozoides os scores de Johnsen devem ser superiores a 8,2 (bilateral) e o dígito II de Copenhagen inferior a 2,5 em ambos os testículos. Todavia, para a motilidade progressiva de espermatozoides o score de Johnsen deve ultrapassar a 9,1 (bilateral) e na avaliação da morfologia espermática, este deve se apresentar acima de 7,9 e com volume testicular acima de 13,6 mL (lado direito). Quanto aos valores de corte obtidos no grupo 2, para a concentração de espermatozoides, os scores de Johnsen devem ser superiores a 5,5 com volume testicular acima de 11,5 mL em ambos os testículos. Finalmente, quanto à motilidade espermática total e progressiva, o dígito III do índice de Copenhagen deve ser inferior a 1,5 (lado direito). CONCLUSÃO: Valores prognósticos da melhora da capacidade reprodutiva obtidos por meio de biópsia testicular podem auxiliar com eficácia no prognóstico e na avaliação dos pacientes candidatos à correção microcirúrgica da varicocele / BACKGROUND: Infertility affects approximately 15% of couples in reproductive age and profoundly changes the lives of these people. Among the identifiable causes of male infertility, varicocele is the most common and affects about 40% of infertile or subfertile men. One of the challenges in the surgical approach is the identification of individuals who will present benefits with the treatment, since many patients do not show improvement of semen analysis. OBJECTIVE: To identify a testicular histological pattern as prognostic value of improved reproductive capacity in patients submitted to microsurgical correction of varicocele. METHODS: we retrospectively analyzed bilateral testicular biopsies of 60 men attending specialized clinic of male fertility between the years 2006 and 2014. As inclusion criteria were considered men diagnosed with clinical and subclinical varicoceles between 19 and 50 years old with results of testicular histopathology and seminal analysis. The patients were divided into two groups. Group 1: Men diagnosed with subclinical varicocele (n = 20). Group 2: men diagnosed with clinical varicocele (n = 40). Men diagnosed with cryptorchidism, obstructive and non-obstructive azoospermia, users of drugs and anabolic steroids were excluded of the study. All Participants were submitted to urological physical examination with the evaluation of testicular volume by ultrasonography of the scrotum with Color Doppler. The diagnosis of varicocele was performed by careful palpation of pampiniform plexus with the patient in standing position. The Valsalva maneuver was used to classify the grade of varicocele. The determination of a testicular histological pattern as prognostic value of the improved reproductive capacity was performed by the creation of cut-off values that associate Johnsen scores, Copenhagen indices and testicular volume to improvement in semen parameters. RESULTS: In Group 1, for improvement of sperm concentration, the Johnsen score must be greater than 8.2 (in the left testicle) and testicular volume must be greater than 12.8 mL (in the right testicle). Concerning evaluation of sperm total motility, the Johnsen score must be greater than 8.2 (bilateral) and digit II of Copenhagen indices must be less than 2.5 (bilateral). However, for sperm progressive motility, the Johnsen score must exceed 9.1 (bilateral) and evaluation of sperm morphology must be greater than 7.9 with right testicular volume greater than 13.6 mL. In Group 2, the cut-offs values for sperm concentration indicates that Johnsen scores must be greater than 5.5 with testicular volume greater than 11.5 mL in both testicles. Finally, regarding the sperm total and progressive motility, the digit III of Copenhagen indice must be less than 1.5 (in the right testicle). CONCLUSION: Prognostic values of improved reproductive capacity obtained from testicular biopsy can assist effectively in the prognosis and evaluation of patients candidates for microsurgical correction

Em sete adolescentes com dermatomiosite (DM) juvenil (DMJ) foi avaliada a função gonadal através do estadiamento puberal, aspectos da sexualidade, exame físico da genitália e exames complementares: análise seminal (duas amostras com intervalo de um mês), anticorpos anti-espermatozóides, ultra-sonografia escrotal e dosagens hormonais (testosterona, hormônio estimulante do folículo, hormônio luteinizante, prolactina, T3, T4, T4 livre e TSH). Todos os pacientes apresentaram terazospermia, dois tiveram varicocele e um anticorpo anti-espermatozóide localizado em peça intermediária. A futura fertilidade destes pacientes é incerta e estudos de prevalência de função gonadal em populações de jovens e adultos do sexo masculino com DM são necessários / In seven adolescents with dermatomyositis (MD) juvenile (JDM), gonadal function was evaluated through the puberal estadiamento, aspects of the sexuality, examination of the genitalia, semen analysis (two semen samples over a period of one month), anti-sperm, testicular ultrasound and hormones (testosterone, follicle stimulating hormone, luteinizing hormone, prolactin, T3, T4, free T4 and TSH).

Em sete adolescentes com dermatomiosite (DM) juvenil (DMJ) foi avaliada a função gonadal através do estadiamento puberal, aspectos da sexualidade, exame físico da genitália e exames complementares: análise seminal (duas amostras com intervalo de um mês), anticorpos anti-espermatozóides, ultra-sonografia escrotal e dosagens hormonais (testosterona, hormônio estimulante do folículo, hormônio luteinizante, prolactina, T3, T4, T4 livre e TSH). Todos os pacientes apresentaram terazospermia, dois tiveram varicocele e um anticorpo anti-espermatozóide localizado em peça intermediária. A futura fertilidade destes pacientes é incerta e estudos de prevalência de função gonadal em populações de jovens e adultos do sexo masculino com DM são necessários / In seven adolescents with dermatomyositis (MD) juvenile (JDM), gonadal function was evaluated through the puberal estadiamento, aspects of the sexuality, examination of the genitalia, semen analysis (two semen samples over a period of one month), anti-sperm, testicular ultrasound and hormones (testosterone, follicle stimulating hormone, luteinizing hormone, prolactin, T3, T4, free T4 and TSH).

Το 15-20% των ζευγαριών αντιμετωπίζουν προβλήματα τεκνοποίησης, με την υπογονιμότητα να ορίζεται ως η αδυναμία σύλληψης μετά από ένα έτος συχνών σεξουαλικών επαφών χωρίς τη χρήση αντισυλληπτικών μεθόδων. Η κιρσοκήλη αποτελεί τη συχνότερη διορθώσιμη αιτία ανδρικής υπογονιμότητας. Η επίπτωσή της στο γενικό πληθυσμό κυμαίνεται στο 10-15%, ενώ στους υπογόνιμους άνδρες στο 30%. Ορίζεται ως η παθολογική κιρσοειδής ανεύρυνση του οσχεϊκού τμήματος των φλεβών του σπερματικού τόνου (ελικοειδούς πλέγματος) και εμφανίζεται εκλεκτικότερα αριστερά. Ο ακριβής μηχανισμός με τον οποίο επηρεάζει τη σπερματογένεση δεν είναι πλήρως διευκρινισμένος. Ιδιαίτερο ρόλο, σύμφωνα με πρόσφατες έρευνες, φαίνεται να διαδραματίζει το οξειδωτικό stress. Αυτό προκύπτει από ανισσοροπία μεταξύ παραγωγής Reactive Oxygen Species (ROS) και επαρκούς εξουδετέρωσής τους από αντιοξειδωτικούς μηχανισμούς. Το οξειδωτικό stress πηγάζει από πολυάριθμες πηγές δημιουργίας στο ανδρικό αναπαραγωγικό σύστημα και προκαλεί υπογονιμότητα με δύο βασικούς μηχανισμούς: 1) Βλάβη στο DNA των σπρματοζωαρίων 2) Βλάβη στη μεμβράνη των σπρματοζωαρίων. Η αιτιολογία της αύξησης του οξειδωτικού στρες σε σχέση με τη κιρσοκήλη παραμένει αδιευκρίνιστη (ενοχοποιούνται κυτταροκίνες, το ΝΟ, η λεπτίνη κ.α.). Υπάρχουν διάφοροι μέθοδοι προσδιορισμού της οξειδωτικής βλάβης τόσο στη φλεβική κυκλοφορία όσο και στο σπέρμα, χωρίς ωστόσο να αποτελούν εξετάσεις ρουτίνας στα ανδρολογικά εργαστήρια. Από τους in vivo χρησιμοποιούμενους αντιοξειδωτικούς παράγοντες σημαντικότεροι είναι η Βιταμίνη Ε, C και το Coenzyme Q-10. Βελτιώνουν την ποιότητα του σπέρματος, ενώ είναι λιγότερο εμφανές κατά πόσο οδηγούν και σε αύξηση του ποσοστού των κυήσεων. Η περαιτέρω κατανόηση του ρόλου του οξειδωτικού stress έχει να προσφέρει πολλά στην ακριβέστερη γνώση των μοριακών μηχανισμών με τους οποίους η κιρσοκήλη οδηγεί σε υπογονιμότητα. Αυτό είναι απαραίτητο για να μπορέσουμε μελλοντικά αφενός να προβλέπουμε τις πιθανότητες αποκατάστασης της γονιμότητας μετά τη χειρουργική αντιμετώπιση και αφετέρου να ανευρεθεί ο τρόπος με τον οποίο οι εναλλακτικοί-επικουρικοί τρόποι θεραπείας (π.χ. η χορήγηση αντιοξειδωτικών συμπληρωμάτων) θα έχουν το βέλτιστο αποτέλεσμα. / 15-20% of the couples face the problem of fertility. Infertility is the incapability of conception, after one year of frequent trying without using any means of contraception. Varicocele is the most frequent curable reason of male infertility. It is found in the 10-15% of general population and in the 30% of infertile men.It is an abnormal enlargement of the vein that is in the scrotum draining the testicles. Varicole causes infertility in a way that it is not completely understood. According to recent studies, oxidative stress seems to play an important role. Oxidative stress is due to the imbalance between production of Reactive Oxygen Species (ROS) and antioxidant mechanisms. It causes infertility with 2 basical ways:1)Damage in the DNA of sperm 2)Damage in their membrane. It is not known the way by which oxidative stress is induced in patients with varicocele (maybe IL-1,leptin or NO are responsible). There are several ways of measuring oxidative stress in sperm. However they cannot be used in everyday practice. Vitamin E,C and Coenzyme Q-10 are the most widely used in vivo antioxidant supplements. Although they make better the sperm parameters they don't rise ,for sure, the rate of pregnancy. The better knowledge,in the future, of the role of oxidative stress in patients with varicocole can help finding the way by which means of cure such as antioxidant supplements can have the best result.

INTRODUÇÃO: A varicocele é a dilatação das veias do plexo pampiniforme do testículo. A associação entre a varicocele e a infertilidade é diagnosticada em 20 a 40% dos homens inférteis. Atualmente, o estudo ultrassonográfico da varicocele é realizado com o paciente na posição supina antes e durante a realização de Valsalva, levando-se em consideração o diâmetro das veias (> 0,20cm), e a presença de refluxo maior que 1, segundo ao estudo Doppler espectral. OBJETIVO: A) Propor uma nova metodologia na avaliação ultrassonográfica da varicocele. B) Avaliar a concordância dos achados no exame ultrassonográfico com Doppler colorido dos vasos dos plexos pampiniformes e as alterações no espermograma na infertilidade masculina. C) Avaliar a correlação entre o diâmetro de um dos vasos dos plexos pampiniformes e as alterações no espermograma na infertilidade masculina. MÉTODOS: Foram examinados 266 pacientes, provenientes do setor de reprodução humana do Hospital das Clínicas da Universidade de São Paulo (HCUSP), por meio de duplex Doppler colorido, inicialmente com o paciente em decúbito dorsal e posteriormente, após 5 minutos de espera, na posição ortostática, realizando as medidas dos diâmetros transversais dos plexos pampiniforme nas duas posições, tanto em repouso como em Valsalva. Ao estudo pulsado foi considerado refluxo patológico apenas quando persistia por mais de 1 segundo, com uma velocidade superior que 2 cm/s. Estes pacientes também foram submetidos a analise seminal. RESULTADOS: Em relação à metodologia de realização do exame, observou-se aumento no diâmetro do plexo pampiniforme apenas com a variação da posição de cerca de 18% à direita e 5,9% à esquerda, bem como aumento na detecção do refluxo venoso na posição ortostática, de 23% à direita e 6,8% à esquerda. Observou-se também correlação direta entre as alterações no espermograma com o refluxo venoso, 65% à direita e 86% à esquerda, o mesmo não ocorrendo com o diâmetro do plexo pampiniforme. CONCLUSÕES: A) O exame de ultrassongrafia com Doppler colorido deve ser realizado na posição ortostática, após um período de latência de no mínimo cinco minutos, com condições ambientais confortáveis e manobra de esforço. B) Houve concordância significativa entre o refluxo venoso nos plexos pampiniformes e as alterações do espermograma. C) Não há correlação significativa entre o diâmetro de um dos vasos dos plexos pampiniformes e o espermograma / INTRODUCTION: Varicocele is the dilatation of the veins of the pampiniform plexus of the testicle. The association between varicocele and infertility is diagnosed in 20 to 40% of the infertile men. Currently, in the ultrasound study of varicocele, the diameter of the veins is carried through with the patient in the supine position, before and during the Valsalva maneuver, taking the diameter of the veins consideration (> 0,20cm), and a more than 1 second bigger presence of reflux according to spectral Doppler study. OBJECTIVE: A) To consider a new methodology in the ultrasonographic evaluation of varicocele. B) To evaluate the agreement of the findings in the colorful Doppler ultrasonographic examination of the pampiniform plexus vases with the alterations in the spermogram in masculine infertility. C) To evaluate the correlation between the diameter of one the pampiniform plexus vases and the alterations in the spermogram in the masculine infertility. METHODS: 266 patients from the reproduction sector human being of the Hospital of the Clinics of the University of São Paulo (HCUSP) had been examined, by means of colorful duplex-Doppler, initially with the patient in dorsal decubitus and later, after 5 minutes, in the orthostatic position, carrying through the transversal measures of the diameter of the pampiniform plexus in the two positions, in rest and in Valsalva. To the pulse study reflux was considered pathological only when persisted for more than 1 second, with speed superior to 2 cm/s. These patients were also submitted to seminal analysis. RESULTS: Regarding the methodology of accomplishment of the examination, an increase in the diameter of pampiniform plexus was noted only with the variation of the examination position, about 18% to the right and 5,9% to the left, as well as an increase in the detection of venous reflux in the orthostatic position, 23% to right and 6,8% to the left. It was also detected a correct correlation between variations in the spermogram and the venous reflux, 65% to the right and 86% to the left, the same not occurring with the diameter of pampiniform plexus. CONCLUSIONS: A) The colorful Doppler ultrasound examination must be carried through in the orthostatic position, after a period of latency of at least five minutes, with comfortable environement conditions and effort maneuver. B) A significant accordance between the pampiniform plexus venous reflux and the alterations of the spermogram. C) It does not have significant correlation between the diameter of one of the pampiniform plexus vases and the spermogram

Objetivo: Avaliar a função testicular em pacientes do sexo masculino com espondilite anquilosante (EA). Métodos: Vinte pacientes com EA e vinte e quatro adultos masculinos saudáveis foram avaliados quanto às características demográficas, exame urológico, ultrassonografia testicular, avaliações dos espermatozóides, anticorpo anti-espermatozóide e perfil hormonal. Critérios de seleção foram: período de pelo menos 3 meses sem o uso de sulfasalazina e metotrexato e nunca terem usado agentes biológicos ou imunossupressores. As avaliações da EA incluíram investigações clínica e laboratorial. Resultados: A mediana da idade atual foi similar no grupo controle e EA (p=0,175). A freqüência de varicocele foi significantemente maior nos pacientes com EA em comparação com os controles (40% vs 8%, p=0,027). A mediana das formas normais de espermatozóides foi similar em pacientes com EA versus controles [17,25 (2-32,5) vs. 22,5 (1,5-45)%, p=0,215], assim como os outros parâmetros dos espermatozóides (p>0,05). Em contraste, a mediana das formas normais de espermatozóides foi significantemente menor em pacientes com EA com varicocele versus aqueles sem varicocele [13,5 (2-27) vs. 22 (10-32,5)%, p=0,049]. Reforçando esse achado, não foi observada nenhuma diferença nesse parâmetro comparando pacientes com EA e controles sem varicocele (p=0,670). Além disso, outros fatores relevantes para a disfunção testicular (anticorpo anti-espermatozóide, hormônios, marcadores inflamatórios e escores da EA) foram comparáveis em pacientes com e sem varicocele (p>0,05). Conclusão: Nós identificamos uma freqüência alta de varicocele em pacientes com EA associada a anormalidades espermáticas, contudo sem associação com tratamento, anticorpos anti-espermatozóides, alterações hormonais ou parâmetros da doença. A exclusão desses fatores sugere que a varicocele pode ser a responsável pela disfunção testicular em pacientes com EA e não o processo da doença ou a autoimunidade. Investigação da varicocele deve ser sempre realizada em pacientes com EA e problemas de fertilidade / Objective: To assess reproductive function in male ankylosing spondylitis (AS) patients in comparison to healthy controls. Methods: 20 AS patients were compared to 24 male healthy subjects in regard to demographic data, urologic examination, testicular ultrasound (US), semen analysis, anti-sperm antibodies and hormone profile. Exclusion criteria were present use of sulfasalazine or methotrexate, and ever use of biological/cytotoxic agents. Disease activity of AS was evaluated by clinical and laboratory assessments. Results: Demographic data were similar in AS and controls (p=0.175). Varicocele was significantly more frequently found in AS patients than in controls (40% vs. 8%, p=0.027). Semen analysis revealed no significant differences in sperm quality between AS patients and controls (p>0.05). In contrast, the median of normal sperm forms was significantly lower in AS patients with versus those without varicocele [13.5 (2-27) vs. 22 (10-32.5) %, p=0.049] whereas no difference in sperm morphology was observed comparing AS patients and controls without varicocele (p=0.670). Comparison of AS patients with and without varicocele showed that anti-sperm antibodies, hormones, inflammatory markers and disease activity scores did not contribute to the impaired sperm morphology observed in AS patients with varicocele. Conclusion: An increased frequency of varicocele was found in AS patients associated with sperm abnormalities, but independent of therapy, anti-sperm antibodies, hormonal alterations or disease parameters. The exclusion of these factors suggests that varicocele may underlie testicular dysfunction in AS patients and not the disease process or autoimmunity. Investigation for varicocele should be done in AS patients with fertility problems