在正常男性,精索靜脈曲張的發生率大約有15%左右,而在男性不孕症患者的評估中,則高達35%的患者有精索靜脈曲張的問題(1,2)。雖然它真正的病理生理病機轉尚未完全了解,但對於睾丸造精作用(spermatogenesis)的不良影,已有臨床實驗依據及動物實驗模式的證實,使得它在男性不孕因子中,成為最普遍可矯正的疾病之一(3,4,5)。雖然對於精索靜脈曲張手術後的效益(effectivenss)還有些爭議,不過絕大多的文獻都指出,精索靜脈曲張在矯治後,其精蟲品質及受孕率的確有進步。根據Pryor和Howards在1987從15個報告,總共2266個病人的研究中指出,在精索靜脈曲張手術(varicocelectomy)後,平均有66%(range, 51% to 78%)的患者,精蟲品質有明顯的改善,尤其是精蟲活動力的改善更屬明顯,而術後受孕率(pregnancy rate)則介於24%到53%之間(1)。
Goldstein等人在1992年的報告也指出利用顯微手術治精索靜脈曲張後,精蟲的平均濃度從36.97 x 10/cc上升到46.85x10/cc,活動矯力從39.2%升到45.66%,正常形態從48.2%增加到52.1%,一年內受孕率則高達43.47%(6)。Cayan等人在2000年的報告也指出術後的受孕率為42.8%(7)。最近我們研究254個利用較為簡單省時的放大鏡下高位鼠蹊部精索靜脈曲張截除術後的病人,一年內的受孕率也達37.3%(8)。當然大部份像這樣報告,它的缺點是其病例數可能不多,也沒有機分配的對照組,很難有一個絕對清楚的結論。一篇針對總共有12個有對照組的研究所做的分析指出,在精索靜脈曲張手術後,一年的平均懷孕率可達33%,相對沒有治療的對照組,其孕率則僅有16%。
結論
精索靜脈曲張是不孕男性常見的發現,雖然還有些爭議,但有不少的證據顯示長期的精索靜脈曲張會造成睾丸功能的下降,而精索靜脈曲張的矯治可預防睾丸功能的繼續變差,並改善(reverse)部份睾丸既有的傷害。從解剖觀點來看,經由鼠蹊部位(inguinal or sub-inguinal)施行矯治是最佳的地方,而借助顯微手術的技巧,可減少併發症及復發率。在較高位的鼠蹊部(high inguinal),血管分支少,借助簡單的放大鏡(loupe)就可輕易完成的手術,省時又有效,也是不錯的選擇之一。
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