Pentoxifylline and antioxidants improve sperm quality
in male patients with varicocele
We examined the effect of 12 weeks of daily oral administration of pentoxifylline with zinc and folic acid on the
semen quality of 36 men with varicocele-associated infertility in an open, uncontrolled study. After 4 weeks of
treatment, the proportion of morphologically normal sperm cells was significantly increased; these changes per-
sisted until at least 4 weeks after the end of treatment. (Fertil Steril 2009;91:1536–9. 2009 by American
Society for Reproductive Medicine.)
Varicocele is a vascular lesion of the pampiniform plexus in
the spermatic cord. The prevalence of varicoceles in the
general population is estimated to be 15%–20%. However,
the prevalence among men attending infertility clinics is
30%–40%, suggesting that this disorder is a risk factor for
male factor infertility (1).
The pathophysiology of varicocele remains a subject of
debate. Several possible mechanisms have been proposed,
involving, for example, the role of increased intrascrotal
temperature, changes in testicular blood flow and venous
pressure, reflux of renal and/or adrenal metabolic products,
hormonal dysfunction, autoimmunity, defects in acrosome
reaction, and oxidative stress (2). Recent molecular and ge-
netic studies have provided further insight into the causes
of decreased semen quality and altered sperm function in
men with varicoceles: increased apoptosis among develop-
ing germ cells, which may give rise to oligospermia;
increased levels of reactive oxygen species (ROS), which
is associated with reduced sperm motility; and increased
concentration of toxic agents, such as cadmium, in seminal
plasma, which may be involved in abnormal sperm
morphology (3).
Current treatments offered for varicocele-associated in-
fertility are surgery or assisted reproductive technology
(ART) (4). Drug-based treatment has been seldom investi-
gated. Combined administration of oral carnitine and intra-
rectal cinnoxicam may improve seminal characteristics in
patients with varicocele (5, 6).
We used pentoxifylline combined with zinc and folic
acid in an open, uncontrolled study to determine whether
this class of drugs, acting on testicular vascularization,
oxidative stress equilibrium, and DNA integrity, could im-
prove seminal characteristics in patients with varicocele-
associated infertility and favor pregnancy. We obtained
approval for this study from the Institutional Review
Received June 7, 2008; revised and accepted September 4, 2008;
published online November 5, 2008.
A.O. has nothing to disclose. A.D. has nothing to disclose. L.M. has noth-
ing to disclose.
Reprint requests: Luc Multigner, M.D., INSERM U 625, Campus de
Beaulieu, Universite Rennes 1, 35042 Rennes cedex, France (FAX:
33–223–235-055; E-mail: luc.multigner@rennes.inserm.fr).
1536 Fertility and Sterility Vol. 91, No. 4, Supplement, April 2009
Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc.
Board of the Hospital Italiano Garibaldi of Rosario,
Argentina.
We enrolled 36 male partners from couples who had con-
sulted for infertility screening. The inclusion criteria were
the presence of varicocele (grade III or more), assessed by
clinical parameters and echo Doppler color scanning; one
or more seminal characteristics with values below the rec-
ommended World Health Organization (WHO) values (7)
in two baseline semen samples taken the month before the
start of the treatment period; the absence of current seminal
infection, confirmed by negative bacterial culture; the ab-
sence of leukocytospermia or endocrinopathies; and the ab-
sence of female factor infertility factors. The mean age of
the patients was 35 years (range, 29–44). The median period
of waiting time to pregnancy was 2 years (range, 1–14).
Thirty of the 36 men consulted for primary sterility. Nine
(25%) patients had a seminal volume below 2 mL, 19
(53%) had sperm concentration below 20  106/mL, 18
(50%) had sperm output below 40  106/mL, 19 (53%)
had total sperm motility below 50%, and in 25 (69%) pa-
tients normal sperm morphology was below 30%. Semen
samples were obtained by masturbation after a recommen-
ded period of 3–5 days of sexual abstinence. Seminal vol-
ume was measured in a graduated pipette, accurate to
within 0.1 mL. Sperm concentration was determined using
a hemocytometer (improved Neubauer counting chamber),
after appropriate dilution. Sperm motility was assessed by
direct observation under a microscope (400). Sperm mor-
phology and semen cytology, including identification of
white blood cell, was assessed by staining slides (May
Grunwald-Giemsa staining) and direct observation under
a microscope (1000). All seminal analyses were carried
out by the same technician. Intraobserver variation was
evaluated several times before and during the study. Coeffi-
cients of variation were between 3% and 10% depending on
the seminal characteristic analyzed.
A daily dose of 1200 mg (600 mg every 12 hours) of pen-
toxifylline, together with 5 mg of folic acid and 66 mg of
zinc sulfate, was administered orally during an uninter-
rupted period of 12 weeks. Semen samples were evaluated
at 4, 8, and 12 weeks during the treatment period and 4
weeks after the last dose (corresponding to week 16 after
0015-0282/09/$36.00
doi:10.1016/j.fertnstert.2008.09.024
Fertility and Sterility

TABLE 1
Semen characteristics before, during, and after treatment.
Before treatment Fourth week of treatment Eighth week of treatment Twelfth week of treatment After treatment
Median Median Median Median Median
Variable n (25th, 75th) (25th, 75th) Pa (25th, 75th) Pa (25th, 75th) Pa (25th, 75th) Pa
Volume of semen,
mL:
All 36 2.6 (1.8, 4.1) 3.0 (2.0, 4.2) NS 2.9 (2.2, 3.7) NS 3.0 (2.3, 3.8) .NS 2.8 (2.3, 4.2) NS
<2 mL 9 1.4 (1.1, 1.7) 1.7 (1.0, 2.6) NS 1.9 (1.3, 3.2) .04 1.3 (1.2, 2.5) .04 2.0 (1.4, 4.1) .04
Sperm
concentration,
106/mL:
All 36 15 (4, 31) 14 (4, 35) NS 10 (5, 36) NS 17 (5, 47) NS 24 (5, 52) NS
<20  106/mL 19 4 (3, 9) 5 (2, 12) NS 5 (2, 10) NS 6 (1, 12) NS 6 (2, 12) NS
Sperm output, 106:
All 36 39 (14, 71) 49 (11, 62) NS 32 (12, 93) NS 56 (15, 110) NS 50 (14, 107) NS
<40  106 18 14 (7, 22) 12 (5, 50) NS 17 (4, 26) NS 14 (6, 46) .05 17 (5, 42) NS
Sperm motility, %
All 36 46 (37, 555) 52 (34, 56) NS 42 (34, 52) .NS 47 (34, 55) .NS 45 (36, 52) NS
<50% 19 39 (23, 41) 45 (24, 55) NS 37 (24, 42) NS 41 (33, 51) .015 37 (29, 53) NS
Normal sperm
morphology, %:
All 36 21 (13, 36) 40 (25, 44) .0005 31 (22, 38) .007 40 (26, 47) < .0001 39 (32, 45) .009
<30% 25 20 (11, 23) 35 (25, 40) < .0001 28 (20, 31) .005 33 (25, 41) < .0001 33 (24, 45) .005
Note: NS ¼ nonsignificant.
a
Paired Wilcoxon rank test.
Oliva. Pentoxifylline, antioxidants, and varicocele. Fertil Steril 2009.
1537
the start of treatment). These time intervals were chosen to
cover the length of one full spermatogenesis cycle (~12
weeks) and to detect any undesirable effects during the
treatment period. Any pregnancies were recorded during
a follow-up period of 6 months after treatment. For each se-
men characteristic, we compared the average of the two
baseline semen analyses to values obtained during and after
treatment. We used the nonparametric paired Wilcoxon
rank test with the Statview software (SAS Institute Inc.,
Cary, NC). P-values were two sided. P<.05 or P<.0125
were considered statistically significant for single or multi-
ple comparisons of each variable, respectively.
Table 1 shows the median and interquartile values (25th
and 75th percentiles) for semen characteristics before, dur-
ing, and after the treatment period. Considering all patients
together, sperm morphology was significantly improved at
week 4; this effect was maintained during and after treat-
ment, suggesting that this change is drug related. No
changes were observed for the other variables. For patients
with seminal markers below the WHO limits, sperm mor-
phology was still significantly improved during and after
treatment. Seminal volume also slightly increased between
weeks 8 and 16, whereas sperm motility was improved at
week 12 as an isolated episode in these patients. Only 24
of 36 patients could be followed until the end of the 6
months after treatment. Fourteen pregnancies were re-
corded during this follow-up period, corresponding to an
overall pregnancy rate of 58%. Eight (33%) were spontane-
ous pregnancies and six (25%) pregnancies were obtained
in patients (n ¼ 6) who underwent intracytoplasmic sperm
injection after 12 weeks of treatment. In the absence of
a control group, we could perform only a limited compari-
son with data obtained from previously published series of
infertile couples for which the man had clinical varicocele
and underwent other procedures to control the pathology.
Alternate surgical procedures for treating varicocele has re-
sulted in spontaneous pregnancy rates between 28% and
40% after a follow-up of 12 months (8) or 39% after
a mean follow-up of 38 months (9). When surgery was
combined with ART, an overall pregnancy rate of 53%
was observed after a mean follow-up of 38 months (9).
We did not observe any adverse effects related to treat-
ment during our study. Folic acid and zinc sulfate have
not previously been associated with adverse effects at the
administered doses. Pentoxifylline is a peripheral vasodila-
tor and could therefore induce hypotension; thus, arterial
pressure should be controlled during treatment with this
drug.
Particular properties of pentoxifylline, zinc, and folic
acid may explain the effect on sperm morphology. Previous
studies have reported a significant increase of DNA-dam-
aged spermatozoa and increased seminal ROS levels in pa-
tients with varicocele (10). Consequently, seminal oxidative
stress may be involved in sperm DNA damage, which in
turn may affect the quality of the ejaculated spermatozoa.
1538 Oliva et al. Correspondence
Pentoxifylline can attenuate oxidative metabolism and pre-
serve antioxidant enzyme activities (11). Moreover, folic
acid and zinc are essential for DNA synthesis, which plays
a major role in spermatogenesis (12). It remains to be estab-
lished whether such mechanisms underlie the improve-
ments observed in sperm morphology. The measurement
of ROS, antioxidants, and DNA integrity in semen, during
and after treatment, should help to confirm the mechanism
involved. We also observed some improvement in seminal
volume and, to a lesser extent, in sperm motility. Such
effects may be linked to the well-established vascular and
rheological properties of pentoxifylline (11).
Among the variables studied, sperm morphology was the
most frequently affected before treatment and the most ex-
tensively improved by treatment in our study population.
We may speculate that the improvement of sperm morphol-
ogy from the fourth week after treatment suggests that late
stages of spermatogenesis may be a target of treatment.
Sperm morphology is a major factor affecting the successful
outcome of ART (13). Therefore, treatment with a combina-
tion of oral pentoxifylline, zinc, and folic acid could be ben-
eficial for patients with varicocele-associated altered
morphology when ART is indicated.
Our findings are encouraging; however, a double-blind
study with a control group will be needed to confirm our
results.
Alejandro Oliva, M.D.a
Alejandro Dotta, M.D.a
Luc Multigner, M.D.b,c
a
Unidad de Andrologia, Servicio de Urologia, Hospital
Italiano de Rosario, Rosario, Argentina; b Institut
National de la Sant
e et de la Recherche M edicale
(INSERM), Groupe d’Etudes sur la Reproduction
chez l’Homme et les Mammif eres (GERHM),
and c Universit
e Rennes 1, Rennes, France
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