Can Hernia Repair With Mesh Impact Ejaculate Volume?

• Journal List
• Reprod Health
• five.15; 2022
• PMC5914038

Reprod Health. 2022; 15: 69.

Does the use of hernia mesh in surgical inguinal hernia repairs cause male infertility? A systematic review and descriptive assay

Zhiyong Dong

¹Department of Surgery, the Starting time Affiliated Infirmary of Jinan Academy, No. 613. Huangpu Avenue Due west, Guangzhou, 510630 Red china

²Robert H. Lurie Comprehensive Cancer center, Division of Reproductive Science in Medicine, Feinberg School of Medicine, Northwestern University, 303 East. Superior Street, Suite 4-121, Chicago, IL 60611 Us

Stacy Ann Kujawa

²Robert H. Lurie Comprehensive Cancer heart, Partition of Reproductive Science in Medicine, Feinberg School of Medicine, Northwestern University, 303 Eastward. Superior Street, Suite 4-121, Chicago, IL 60611 Us

Cunchuan Wang

¹Department of Surgery, the First Affiliated Hospital of Jinan University, No. 613. Huangpu Avenue West, Guangzhou, 510630 China

Hong Zhao

^twoRobert H. Lurie Comprehensive Cancer center, Division of Reproductive Science in Medicine, Feinberg School of Medicine, Northwestern University, 303 Due east. Superior Street, Suite 4-121, Chicago, IL 60611 Usa

Received 2022 Jul xiv; Accepted 2022 Apr eighteen.

Abstract

Objective

The aim of this study was to systematically review the available clinical trials examining male infertility after inguinal hernias were repaired using mesh procedures.

Methods

The Cochrane Library, PubMed, Embase, Web of Science, and Chinese Biomedical Medicine Database were investigated. The Jada score was used to evaluate the quality of the studies, "Oxford Eye for Testify-based Medicine-Levels of Testify" was used to assess the level of the trials, and descriptive analysis was used to evaluate the studies.

Results

Twenty nine related trials with a total of 36,552 patients were investigated, including seven randomized controlled trials (RCTs) with 616 patients and 10 clinical trials (1230 patients) with mesh or non-mesh repairs. The Jada score showed that in that location were vi high quality RCTs and one low quality RCT. Levels of evidence adamant from the Oxford Centre for Evidence-based Medicine further demonstrated that those 6 high quality RCTs too had high levels of evidence. Information technology was found that serum testosterone, LH, and FSH levels declined in the laparoscopic group compared to the open group; still, the testicular volume only slightly increased without statistical significance. Testicular and sexual functions remained unchanged after both laparoscopic transabdominal preperitoneal hernia repair (TAPP) and totally extra-peritoneal repair (TEP). We too compared the different meshes used post-surgeries. VyproII/Timesh lightweight mesh had a diminished issue on sperm motility compared to Marlex heavyweight mesh after a i-twelvemonth follow-up, but there was no outcome after 3 years. Additionally, diverse open hernia repair procedures (Lichtenstein, mesh plug method, posterior pre-peritoneal mesh repair, and anterior tension-free repair) did not cause infertility.

Conclusions

This systematic review suggests that hernia repair with mesh either in an open up or a laparoscopic procedure has no significant event on male fertility.

Keywords: Inguinal hernia repair, Mesh, Male infertility, Systematic review

Plain English summary

The incidence of inguinal hernia is steadily decreasing subsequently the application of mesh and laparoscopic techniques; however the utilise of mesh causing infertility is becoming a growing concern. Whether there are any furnishings on male fertility after open up/laparoscopic mesh inguinal hernia repair is even so a controversial topic. Thus, the aim of this study was to systematically review the bachelor clinical trials for male infertility after inguinal hernia repair with mesh. The Jada score and Oxford Eye for EBM Levels of Evidence were used to evaluate the quality or evidence level of the included studies. Finally, 29 related trials were investigated. The results indicated that polypropylene mesh inguinal repair did not change male infertility after open or laparoscopic mesh repair, TAPP versus TEP additional procedures of repair, or contrasted mesh types. This study suggests that hernia repair with mesh either in an open or a laparoscopic procedure has no significant consequence on male infertility according to current evidence. Notwithstanding, whether sperm should be stored and assessed for quality purposes prior to procedures for patients who have fertility bug, is worthy of further study.

Groundwork

Tension-free mesh hernia repair has become the standard process in inguinal hernia repair after the concept of tension-gratuitous hernia repair was proposed by Lichtenstein in 1989 [1]. Currently, the principal operating procedures for inguinal hernia repair involve either open or laparoscopic hernia repair with mesh [2, 3]. The meshes used for these procedures are composed of biomaterial or biological material including polypropylene, Marlex, VyproII, TiMesh, and Prolene [4, 5]. The incidence of inguinal hernia has decreased after the application of mesh and laparoscopic techniques, but the apply of mesh causing infertility is becoming a growing business.

It has been reported that the complications of mesh hernia repair are infection, pain, adhesions, seroma, intestinal obstruction, and recurrence [6, seven]. Indicators for diagnosing male infertility commonly include the testicular volume, testicular resistivity index, serum testosterone, serum gonadotrophins (FSH, follicle-stimulating and LH, luteinizing hormone), and semen quality (volume, concentration, motility, α-glucosidase, and morphology). Mesh inguinal hernia repair may cause infertility past influencing the spermatic duct structure in white male rats [eight]. In men, 14 cases of azoospermia secondary to inguinal vasal obstruction were reported in relation to previous polypropylene mesh hernia repair [nine]. A randomized controlled trial (RCT) with 59 male patients was used to evaluate male person fertility between heavyweight meshes (Marlex) and lightweight meshes (Vypro Two/TiMesh) at a one-yr follow-upward. Semen analysis showed that lightweight meshes for laparoscopic inguinal hernia repair negatively influenced sperm motility [10]. Contrarily, Tekatili et al. summarized 16 clinical studies and indicated that the lightweight mesh did not seem to have an touch on male fertility in inguinal hernias [xi]. The only previous systemic review besides supported that there is non an impact on male fertility afterwards mesh hernia repairs [12]. Therefore, the function of mesh usage in male fertility in hernia repair patients remains unclear.

To circumvent the limitation of the previous review, we have included several additional RCTs and control trials on male person infertility and hernia repair published from 2022 to 2022 [12–19], detailed sub-group analyses, and boosted databases and clinical trials. In improver, the Jada score and levels of evidence from Oxford Centre for Evidence-based Medicine were used to appraise the quality of included studies. Our near comprehensive systemic review analyzed the possible effect of mesh usage on male fertility in hernia repair, including different open and laparoscopic procedures and diverse types of surgical mesh. This written report provides a robust bear witness-based answer to support clinical decisions.

Methods

Search strategy

The related literature was searched on February 14th, 2022 from the following electronic databases: PubMed, Embase, Fundamental (Cochrane Library), Web of Science, CBM (Chinese Biomedical Medicine Database), and other resources [WHOITRP (World Health Organization International Trials Registry Platform search portal, http://www.who.int/trialsearch/), ATCR (Australian New Zealand Clinical Trials Registry, http://world wide web.anzctr.org.au/), ISRCTN (International Standard Randomized Controlled Trial Number Register, http://www.controlled-trials.com/), TC (Trials Central, www.trialscentral.org/), and CCTR (Chinese Clinical Trial Annals, http://world wide web.chictr.org.cn/)]. The post-obit search strategy was used: ("polypropylene mesh" or "absorbable mesh" or "mesh" or "meshes") and ("herniorrhaphy" or "hernioplasty" or "inguinal hernia repair" or "laparoscopic transabdominal preperitoneal hernia repair" or "totally actress-peritoneal repair") and ("male infertility" or "fertility" or "azoospermia" or "sperm motility"). There were no language restrictions in this report.

Inclusion and exclusion criteria

Clinical studies (RCTs, cohort studies, instance controlled trials, case serial, and example reports) were considered for this study. Review articles and messages to editors and unrelated papers were excluded. The report subjects were limited to men. The following outcomes were considered: testicular volume, testicular resistivity index, serum FSH, serum testosterone, serum LH, semen volume, α-glucosidase (mU), sperm morphology, sperm assay (superlative systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI), resistivity alphabetize (RI)), and sperm concentration.

Data extraction and quality evaluation

All studies coming together the inclusion and exclusion criteria were retrieved by screening abstracts (DZ and WC). 2 reviewers (DZ, WC) independently extracted the following terms by a cocky-made grade generated from data included in each written report: first writer'southward family name, publish twelvemonth, state, type of surgery, study design, total number of patients, age, type of mesh, hernia side, outcomes, and the follow-upwards period. Whatever disagreements were resolved by joint discussion among reviewers, and the author was contacted if at that place was whatsoever missing data. The methodological quality of the included studies was assessed according to Jada scoring. The assess terms were: adequate sequence generation (0–two points), allocation concealment (0–two points), blinding (0–2 points), and follow-up/withdraw (0–2 points). For these assessments, one to 3 points were considered low quality and iv to 7 points were accounted high quality. Methodological quality assessment was independently performed by two reviewers (DZ and WC) [20, 21]. The Oxford Centre for Evidence-based Medicine – Levels of Bear witness (http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-bear witness-march-2009/) (Level I to Level 5, level I was considered high level of testify, level 5 was considered depression level of prove) was used to assess the level of the clinical trials.

Statistical analysis

There was insufficient information included in the RCTs to perform the meta-assay, so descriptive analysis was performed for these studies. The descriptive analysis was used if there was high clinical or statistical heterogeneity, and the subgroup analysis was used for loftier and low quality included studies or different interventions. The sensitivity analysis was performed when heterogeneity comes from the different methodological qualities of the included trials. Case control trials, cohort studies, retrospective, or case reports were also investigated by descriptive assay. The egger'due south exam and Begg's exam were not used to explore the possibility of publication bias due to insufficient data included in the studies [22–26].

Results

Search strategy

A total of 234 studies were identified for screening via title and abstract according to our search strategy. Among them, 137 studies were excluded for the same cross-duplicated articles, animal studies, and unrelated literature. The remaining 97 potentially relevant studies were identified later on screening by abstruse, in which 68 studies were excluded considering they were reviews, letters to the editor, diagnosis studies, and studies that did not focus on infertility. Consequently, the 29 clinical studies that met the inclusion criteria were included by full-text reading [27–48]. Amidst them, there were seven RCTs apropos mesh hernia repair and infertility [10, 13, 28, 31, 35, 44, 45]. Effigy1 displays the details of the search selection procedure.

Menstruation diagram of the search process and study choice

Report characteristics

This comprehensive systemic review focused on studies and reports published betwixt 2003 and 2022 that investigated testicular office, semen, or male person infertility later on hernia repair, and it included 29 studies for a full of 36,916 participants. At that place were xv studies conducted in Europe, 11 studies in Asia, and 3 in America. There were seven RCTs, eight case control studies, 3 cohort studies, 3 case series, four case reports, and three retrospective studies. The surgical operations included LAP (TAPP, TEP) and open (LHR). The main outcomes included: testicular volume, testicular resistivity index, serum FSH, serum testosterone, serum LH, semen volume, concentration, movement, α-glucosidase, morphology, height systolic velocity, end diastolic velocity, pulsatility alphabetize, and obstructive azoospermia with a follow-upwards from vi to 36 months. Table1 demonstrates the characteristics of the included trials [nine, 10, xiii–19, 27–46].

Tabular array ane

Baseline characteristics of the included studies in the systematic review

Study (Author/Year) (Evidence level)	Country	Surgery	Blueprint	Patients (due north)	Mean age (years)	Mesh materials	Hernia side	Outcome measure	Follow-upward (months)
Bansal 2022 (I-1b) [13]	India	TAPP/TEP	RCT	TAPP lxxx	TAPP forty.9 ± 12.3	NS	Unilateral Hernia Bilateral hernia	Testicular functions Sexual functions	3
				VS TEP lxxx	TEP 40 ± 12.five
Krnić 2022 (III-3b) [14]	Croatia	Open	Case-control	Non-complicated hernia 57 VS Incarcerated hernia 64	Group I 57 (40–81)	Bard® mesh	Right Hernia Left Hernia	Testicular blood catamenia	5
					Group 2 64 (28–eighty)
Lal 2022 (Iii-3b) [15]	India	TEP	Cocky Case-control	28	42.four (18–72)	Bard 3DMax™ mesh	unilateral hernia (16 right sided and 8 left sided, 21 indirect and 3 direct hernias) and 4 to have bilateral hernia (2 direct and 2 indirect).	Resistive index	iii
Gvenetadze 2022 (III-3b) [xvi]	Georgia	Open	Case command	Lichtenstein 66 Gvenetadze method 149	19–xl	mesh	Bilateral	Oligospermia, reduction of the quantitative sperm	one,half dozen
Shkvarkovskiy 2022 (Iii-3b) [17]	Russian	Open up	Instance control	New method 61	19–61	Polymeric mesh	Hernia	testicular arteries, testicular volume, sex hormones level.	NS
				Lichtenstein 63
Yan 2022 (IV-iv) [xviii]	China	Open	Retrospective study	142	24.0 ± two.0	mesh	Unilateral	Infertility Sex function	3–36
Khodari 2022 (IV-iv) [19]	French republic	Open up	Retrospective study	69	NS	polypropylene mesh	Bilateral (history of hernia repair)	Risk of infertility	NS
Stula 2022 (II-2b) [27]	Croatia	TAPP/Open	Cohort study	TAPP 29	61(33–81)	Prolene mesh	Unilateral Bilateral	testicular blood period (RI, PSV, EDV), ASA	5–6
				Open 53
Peeters 2022 (I-1b) [28]	Belgium	TEP	RCT	Marlex ® 20	twenty–50	(Marlex ®) VyproII ® TiMesh ®	Unilateral 39 Bilateral 20	Semen analysis	36
				VyproII ® 20
				TiMesh ® xix
Schouten 2022 (protocol) [29]	Netherlands	TEP	Accomplice study	21	18–sixty	Prolene	Bilateral inguinal hernias	testicular perfusion and volume, semen quantity and quality endocrinological status	6
Stula 2022 (Ii-2b) [30]	Croatia	TAPP/Open up	Cohort	TAPP15 Open28	62(33–81)	Prolene mesh	Unilateral Bilateral	Testicular, capsular, intratesticular arterial flow dynamics	5
Singh 2022 (I-1b) [31]	India	TAPP, TEP/Open up	RCT	LAP (TAPP, TEP)60 Open up 57	LAP 45.7 ± fourteen.6	mesh	Unilateral Bilateral	Testicular functions (testicular volume, blood menstruum, hormones)	iii
					Open up 45.4 ± 17.8
Hallén 2022 (Iv-iv) [32]	Sweden	Open	retrospective	Open 34,267	23–62	mesh	Unilateral Bilaterally	Risk for infertility	12
						No mesh
Skawran 2022 (Iii-3b) [33]	Deutschland	TEP	Case control	Calorie-free mesh group 21	18–60	Bard TM soft mesh Bard TM flat mesh	Bilateral	Testicular volume and perfusion, serum levels of sexual hormones, ejaculate volume, and number of spermatic cells.	3
				Heavy group 38
Hallén 2022 (III-3b) [34]	Sweden	NS	Case control	With mesh 232	18–55	mesh/ without mesh	Bilateral(344)	Run a risk for infertility	NS
				Without mesh 112
				Control general 202
Peeters 2022 (I-1b) [10]	Belgium	TEP	RCT	Marlex ® 20	20–50	(Marlex ®) VyproII ®	Unilateral 39 Bilateral twenty	Semen analysis, scrotal ultrasonography	12
				VyproII ® twenty		TiMesh ®
				TiMesh ® nineteen
Sucullu 2022 (I-1b) [35]	Turkey	open	RCT	Lichtenstein 32	LG 22 (xx–28)	Polypropylene mesh	Unilateral	Testicular volume, resistive index Testicular function	three
				Mesh plug 32	MPG 23 (20–thirty)
Kiladze 2009 (3-3b) [36]	Georgia	Open up	Case control	Lichtenstein 56	44.8	mesh	Bilateral	Main sperm parameters	6
				Modified Lichtenstein 61
Chu 2009 (IV-4) [37]	USA	Open	Case series	4	NS	mesh	NS	Testicular cloudburst	half dozen
Ramadan 2009 (Three-3b) [38]	Turkey	Open	Case command	Indirect inguinal hernias 48	44.5 (30–73)	mesh	Unilateral straight inguinal hernia	testicular parenchyma, testicular arterial impedance, perfusion, venous flow	2
				Normal contralateral side 48
Yamaguchi 2008 [39] (Five-5)	Japan	Open	Case report	1	30	Polypropylene mesh	Bilateral herniorrhaphy	Hormonal testing Semen analyses Testicular size	15
Brisinda 2008 (IV-iv) [40]	Italian republic	Open	Instance serial	26	NS	mesh	Hernia tension free repair	testicular perfusion	ix
Dohle 2006 (5-5) [41]	Netherlands	open up	Case report	2	35	Polypropylene mesh	Unilateral Bilateral	Semen analysis	3
Langenbach 2006 (I-1b) [42]	Germany	TAPP	RCT	Monofile, heavy-weight, rigid mesh 30 Shine, heavy-weight variant of polypropylene 30 Polyglactin/polypropylene compound mesh xxx	35–75	Rigid mesh Polypropylene Polyglactin/polypropylene	Unilateral	Testicular book	iii
Shin 2005 (IV-4) [9]	USA	LAP/Open up	Case serial	12 LAP two Open+ LAP	35.v (28–42)	Polypropylene mesh	Unilateral Bilateral	Zaoospermia	6–36
Nagler 2005 (V-five) [43]	Usa	Open	Instance written report	i	45	Polypropylene mesh	Correct and left herniorrhaphy	Fructose-positive azoospermia	72
Akbulut 2003 (I-1b) [44]	Turkey	TEP / LHR	RCT	LHR 13 TEP 13	TEP 46.seven ± one.seven LHR 54.two ± 2.half dozen	Polypropylene mesh	Unilateral Bilateral	Testicular function and volume	12
Aydede 2003 (I-1b) [45]	Turkey	Open	RCT	Posterior preperitoneal mesh repair 30 Inductive tension-free repair 30	22 > sixty 38 < sixty	mesh	Unilateral	Testicular flow spermatogenesis	2.5
Yang 1997 (Five-5) [46]	Red china	Open (when child)	Case study	3	xxx/31/50	No mesh	Unilateral Bilateral	Obstructive azoospermia	30 year

TAP laparoscopic transabdominal preperitoneal hernia repair, TEP totally actress-peritoneal repair, LHR lichtenstein hernia repair, LAP laparoscopic hernia repair, Group I non-complicated hernia, Goup II incarcerated hernia. NS non land

Quality assessment of the included studies

Tabular arrayii displays the methodological quality of these studies co-ordinate to Jada scores. Of all of the RCTs, 7 studies reported adequate generation of the allotment sequence and one RCT provided unclear descriptions. Six trials reported allocation concealment [x, thirteen, 28, 35, 44, 45]. Blinding was not reported in any of the RCTs. Patients that were lost to follow-up or withdraw were reported in all studies. At that place were vi studies that were considered loftier quality (v points) and one RCT was low quality (3 points) according to Jada scores. The testify of 7 trials were level I_1b, two were level Two_2b, and all of the RCTS were high level evidence.

Tabular array 2

Quality assessment of RCTs studies (Jada Scores)

1–three points considered as low quality; iv–seven points considered equally high quality

Descriptive analysis

At that place was high clinical heterogeneity among the included studies, so the meta-analysis was non used, and instead, the descriptive subgroup analysis was performed. The groups were divided into laparoscopic hernia repair groups and open up hernia repair groups. Subgroups were divided into the following groups: mesh versus not-mesh, LAP versus Open, TAPP versus TEP, and Marlex mesh versus Vypro mesh. The detailed data from the outcomes of the seven RCTs is shown in Table3.

Tabular array 3

The detailed data from the outcomes of the vii RCTs

Study ID	Surgery	Total No. of patients		Issue and information
		O	C
Bansal 2022 [thirteen]	TAPP VS TEP	eighty	80	Testicular volume: pre-operative, TAPP 13.1 ± i.3, TEP 13.ane ± 1.2; 3 months, TAPP xiii.1 ± 1.3, TEP 13.2 ± 1.1, 6 months TAPP xiii.0 ± 1.3, TEP 13.2 ± i.0 Testicular resistivity index: pre-operative, TAPP 0.64 ± 0.06, TEP 0.61 ± 0.07; 3 months, TAPP 0.634 ± 0.06, TEP 0.6 ± 0.07, 6 months TAPP 0.63 ± 0.06, TEP 0.6 ± 0.07 Serum FSH: pre-operative, TAPP 3.6 ± 0.eight, TEP iii.4 ± 0.viii; 3 months, TAPP 3.6 ± i.0, TEP 3.4 ± 0.8, half dozen months TAPP three.half-dozen ± 0.8, TEP three.4 ± 0.9 Serum testosterone: pre-operative, TAPP iv.2 ± ane,TEP four.0 ± 1.2; iii months, TAPP four.one ± 0.9, TEP iv.0 ± 1.3, 6 months TAPP 4.1 ± ane.0, TEP four.0 ± one.2 Serum LH: TAPP seven.3 ± ane.1,TEP 7.3 ± 1.seven; iii months, TAPP 7.iii ± 1.0, TEP seven.3 ± 1.67, half-dozen months TAPP seven.4 ± i.0, TEP 7.3 ± 1.6
Peeters 2022 [28]	Marlex® VS vyproII® Marlex® VS TiMesh®	12	15/ten	iii year follow-up: Semen volume (ml): Marlex® -0.07 (− 1.1 to 0.6), vyproII® -0.1(− 1.v to 0.2), TiMesh®-0.2 (− 0.9 to 1) Concentration (106 cells/ml): Marlex® -4.four (− 16.1 to 0.5), vyproII® -v.v (− 30.8 to 18.8), TiMesh®-one.65 (− thirty.6 to 17.1) Motility (% progression): Marlex® -two.8 (− 18 to 4.3), vyproII® -eight.5 (− 23 to viii.5), TiMesh®-8 (− 15 to − iv.5) a-glucosidase (mU): Marlex® 3.2 (− xv.5 to 6), vyproII® -v.5 (− 13.7 to 0.2), TiMesh® -one.4(− viii to ane.75) morphology (% normal): Marlex® -2 (− 16 to ii), vyproII® -2.8 (− 9 to 0), TiMesh® -three (− 8.5 to iv)
Singh 2022 [29]	Lap VS Open	60	60	Testicular volume: pre-operative, Lap, 9.8; Open x.vii; iii month, Lap 9.3, Open 9.2 Resistitive index: pre-operative, Lap 0.64, Open 0.68; iii month, Lap 0.58, Open 0.65 FSH: pre-operative, Lap 5,Open up 5.1, 3 calendar month, Lap 5.ane, Open 6.1 LH: pre-operative, Lap four.4,Open 4.v, three calendar month, Lap 4.9, Open five.iv Testosterone: pre-operative, Lap 5.vii,Open five.2, 3 month, Lap 5.5, Open 4.7
Peeters 2022 [10]	Marlex® VS vyproII® Marlex® VS TiMesh®	20	20/19	1 yr follow-up: Semen volume (ml): Marlex® -0.05 (− 0.7 to 0.7), vyproII® -0.43 (− 1.three to 0.3), TiMesh®0.2 (− 0.8 to 0.9) Concentration (106 cells/ml): Marlex® -nine.6 (− 35.5 to thirteen), vyproII® -1.5 (− 21.5 to 10), TiMesh®2.one (10.iii to 15.viii) Motility (% progression): Marlex® -2.0 (− 2 to 10), vyproII® -9.5 (− thirteen.3 to − i), TiMesh®-5.5 (− 17 to − ii) a-glucosidase (mU): Marlex® -iii.6 (− 7.half-dozen to ix.seven), vyproII® -i (− 3.7 to 3.7), TiMesh® 0(− 6.v to one.8) morphology (% normal): Marlex® 0 (− 4.3 to 5.8), vyproII® -1.8 (0 to − v), TiMesh® -1.eight (− half-dozen.viii to 5)
Sucullu 2022 [35]	LG VS MPG	32	32	Testicular volume: pre-operative, LG, 18.92 ± 1.05; MPG, nineteen.37 ± 1.06 3 months, LG 18.75 ± 1.26, MPG 18.21 ± i.26 Resistive index: pre-operative,LG,0.64 ± 0.06, MPG 0.threescore ± 0.04; 3 months, LG 0.80 ± 0.06, MPG 0.75 ± 0.08 Sperm concentration: pre-operative, LG,88.65 ± 10.thirty, MPG 75.27 ± 7.03; iii months, LG 65.48 ± 8.22 MPG 58.87 ± seven.73 Rate of progressive motility: pre-operative, LG 52.79 ± 2.35, MPG 51.64 ± 2.60 3 months, LG 55.54 ± two.26, MPG 48.53 ± ii.96
Akbulut 2003 [44]	TEP VS LHR	13	13	3-calendar month. Testicular volume: pre-operative, TEP, xvi.33 ± 0.71; LHR 15.44 ± 0.87; 3 month, TEP 16.lxx ± 0.88, LHR xiv.fifteen ± 0.96 FSH: pre-operative, TEP half dozen.47 ± 0.63, LHR 8.47 ± 1.11, three month, TEP half-dozen.99 ± 0.86, LHR 9.12 ± 1.57 LH: pre-operative, TEP 4.06 ± 0.40, LHR 5.35 ± 0.57, 3 month, TEP four.72 ± 0.lxx, LHR five.64 ± 0.72 Testosterone: pre-operative, TEP 631.75 ± lx.52, LHR 544.48 ± 36.26, 3 month, TEP 672.00 ± 62.99, LHR 510.64 ± 39.71
Aydede 2003 [45]	TFR VS PPMR	thirty	30	peak systolic velocity (PSV):pre-operative TFR 11.1303 ± 0.6952, PPMR 10.25.twenty ± 0.5033; ii.5 months, TFR 10.8400 ± 0.7084 PPMR 10.4890 ± 0.5194 end diastolic velocity (EDV): pre-operative TFR 3.1257 ± 0.1995, PPMR 3.0287 ± 0.5648; 2.5 months, TFR i.4267 ± 6.544 PPMR 1.2957 ± 8.842 pulsatility alphabetize (PI): pre-operative TFR i.3753 ± 9.177,PPMR ane.3460 ± 0.1082; 2.5 months,TFR 0.7193 ± i.294 PPMR 0.6930 ± 1.887 resistivity index (RI): pre-operative TFR 0.6960 ± 2.192, PPMR 0.6867 ± ii.267; 2.v months, TFR two.8400 ± 0.1973 PPMR iii.0163 ± 0.1880

O observation group, C control group, LG Lichtenstein group, MPG Mesh plug group, TFR Anterior tension-free repair, PPMR Posterior preperitoneal mesh repair

Laparoscopic mesh hernia repair group

There were 12 studies for a total of 1230 patients included in this grouping. The baseline characteristics are shown in Table ​ 1.

Sub-analysis

LAP (TAPP/TEP) versus open group

In the Singh 2022 study (Level I_1b), there were a total of 117 patients with a mean historic period of 45.6 ± xvi.ii years (range 17–79). In Group I, 32 patients underwent TEP and 28 underwent TAPP. Group II had 57 patients that underwent open up mesh repair. The follow-upwards time was preoperatively and postoperatively fix at iii months. There was no significant difference between those ii groups in testicular functions, preoperatively. At that place were statistically significant decreases in the testicular volume, preoperatively and postoperatively in the open group (P = 0.01), but there was no pregnant difference, preoperatively and postoperatively in the LAP group (P = 0.3). There was also statistical significance in the resistive alphabetize, preoperatively and postoperatively in the open grouping (P = 0.07) and the LAP group (P = 0.04). In the LAP group, there was no pregnant difference in FSH levels (P = 0.4) and testosterone (P = 0.3) between preoperatively and postoperatively; yet the decrease was significant in LH levels (P = 0.01) after operation. In the open group, at that place was statistical significance in FSH (P = 0.01), LH (P = 0.001), and testosterone (P = 0.02) betwixt preoperatively and postoperatively. This trial suggested that laparoscopic repair may be more suitable for preserving testicular functions [31]. In the Akbulut 2003 study (level I_1b); in that location were a total of 60 patients with the age of fifty.v ± four.4 (range 24–71). The follow-up fourth dimension was three months. 26 patients were randomized and divided into the TEP group (xiii patients) and Lichtenstein hernia repair (LHR) group (thirteen patients). In that location were no meaning differences betwixt preoperative and postoperative in both groups in regards to LH (P > 0.05) and FSH levels (P > 0.05). However, the subtract was significantly different in the testicular volume and testosterone levels in the TEP group (P < 0.05) compared to the LHR group (P > 0.05). Information technology was indicated that the procedures would non alter LH, FSH, or testosterone values, but TEP could lead to a reduction in testicular book inside the normal limits [46]. Schouten 2022 designed a protocol for cohort studies in social club to evaluate fertility subsequently endoscopic TEP hernia repair, but no information has been published [29]. In Stula 2022 (II_2b), at that place were a total of 543 patients with a mean age of 61 years (ranging 33–81). The follow-upwardly time ranged from five to 6 months. There were 29 patients who underwent TAPP and 53 patients under open up tension-free hernia repair. There was no significant difference between the 2 groups in baseline. The anti-sperm antibodies (ASA) value significantly increased in the open group after operation (P < 0.001), merely at that place was no meaning divergence in the TAPP group (P = 0.133). There was significant change in the resistive alphabetize (P < 0.001) and capsular artery level (P = 0.02) of the resistive index (RI), in patients who underwent TAPP. Cease-diastolic velocity (EDV) showed significant differences on the testicular artery level (P = 0.032) in patients in the open group. This study showed that mesh hernia repairs, open up or laparoscopically, caused but a transitory change in testicular claret menstruation, but there was no clinical significant deviation [27]. In the Stula 2022 study (level II_2b), at that place were a full of 43 patients with 62 years (range 33-81 years). The follow-upwards time was 5 months. There were 15 who underwent the TAPP procedure and 28 in the open up (open up tension-costless hernia repair). This trial indicated that inguinal hernia mesh repairs do not have a clinical significant influence on testicular menses and sperm autoimmunity [thirty].

TAPP versus TEP grouping

In Bansal 2022 (level I_1b), the RCT was divided into the TAPP group with 80 patients and TEP group with 80 patients. The mean age was 40.5 ± 12.4 (rang 18–60). The follow-up fourth dimension was 3 months and 6 months. There was no pregnant divergence in testicular book (P > 0.05), testicular resistivity index (P > 0.05), FSH (P > 0.05), testosterone level (P > 0.05), and LH (P > 0.05) betwixt the ii groups at the 3 calendar month or 6 month follow-up [13].

Unlike meshes comparable groups

In Peters' 2022 written report (level I_1b), there were a full of 59 patients with an age range of 20–50 years. The patients were randomized into three groups: heavyweight polypropylene (Marlex®) with 20 patients, lightweight mesh (VyproII®) with 20 patients, and lightweight mesh (TiMesh®) with 19 patients, and all of the patients underwent TEP. The follow-up was at 1 year. This report suggests that the apply of lightweight meshes for male patients with TEP could influence sperm motility (P = 0.013) at the one yr follow-up [35]. In Peeters' 2022 report (level I_1b), he utilized the same patients every bit Peters' 2022, but the follow-up time was increased to three years. There was decreased sperm move after 1 year, simply at that place was no pregnant difference amongst the three groups in semen volume (P > 0.05), concentration (P > 0.05), motility (P > 0.05), a-glucosidase (P > 0.05) and morphology (P > 0.05) subsequently 3 years. In Langenbach's 2006 study (show, level V), he mentioned a alter in testicular volume, only at that place were no detailed data supporting the ascertainment [28].

LAP group without controls

In this group, there were two studies: Lal 2022 (level Iii_3b) and Skawran 2022 (level 3_3b). In the Lal 2022 report, there were a total of 28 patients: 24 with unilateral hernia, iv with bilateral hernia who underwent TEP. The hateful age was 42.4 years (range xviii–72). The resistive index was followed-up at 24 h, 1 week, and three months and compared preoperatively against postoperatively. In that location was no pregnant divergence in resistive indexes of testicular, capsular, and intratesticular arteries during any fourth dimension postoperatively [15]. In the Skawran 2022 study, at that place were a total of 59 patients with an historic period range of 18–60 years who underwent a bilateral TEP repairs. In the prospectively (light mesh) group, there were 21 patients, the preoperative values were compared with postoperative values, and the follow-up fourth dimension was 3 months. It showed that there were no statistical differences between preoperative and postoperative in testicular book, testicular perfusion, FSH, LH, testosterone, and testicular function (ejaculate volume) (P > 0.05). At that place were 38 patients in the retrospective (heavy mesh) group where the follow-up was determined at ≥3 months. Again, there was no significant divergence between the prospective group and retrospective group in testicular volume, testicular perfusion, FSH, LH, and ejaculate volume (P > 0.05) [33].

Open mesh hernia repair group

Subgroup assay

Compare with dissimilar hernia repair methods

In the Gvenetadze 2022 study (level III_3b), there were a total of 215 patients with an age range from nineteen to 40 years. 66 underwent bilateral Lichtenstein hernia repair and 149 underwent the bilateral Gvenetadze method (a modified Lichtenstein with spermatic cord isolation from a mesh by Gvenetadze. The follow-up times were set at 2 days prior to the operation, thirty days, and half-dozen months post operation. They found oligospermia and a 30–35% reduction of the quantitative sperm in the Lichtenstein group (P < 0.01). However, in that location was no significant departure in the Gvenetadze group [xvi]. In Shkvarkovskiy 2022 written report (level III_3b), in that location were a full of 124 patients with an age range from 19 to 61. 61 had their process with the new method (patent of Ukraine for useful model № 81,728) and 63 underwent the Lichtenstein hernia repair. The outcomes were testicular arteries, testicular volume, and the level of sex hormones. This study was published in Russian and supplied no detailed data [17]. We emailed the author but there was no response. In Sucullu's 2022 study (level I_1b), at that place were a full of 64 unilateral patients with an age range from 20 to 30 years. There were 32 patients in the Lichtenstein grouping and 32 underwent the mesh plug surgery. The follow-up time was 3 months. At that place was a significant increase in the RI in both the Lichtenstein grouping (P = 0.027) and the mesh plug group (P = 0.012), when comparing the preoperative with the postoperative values [35]. In Kiladze's 2009 report (level III_3b), there were a total of 117 bilateral patients with an average age of 44.8 years. The follow-upward time was 6 months. 56 patients were in the Lichtenstein grouping and 117 were with the Gvenetadze grouping. Comparing the morphological parameters of sperm between the pre- and postoperative mesh hernia repair in these 2 groups, the results showed that complete isolation of the spermatic cord from the mesh prevents male infertility after a modified Lichtenstein hernioplast [36]. In Aydede's 2003 study (level I_1b), at that place were a total of 60 patients with xx patients > 60 years old and 38 patients < 60 years one-time. 30 patients with posterior preperitoneal mesh repair (group I) with 30 patients were compared against the anterior tension-free repair (group II) with 30 patients. The follow-upwardly time was pre-operative, early postoperative (the third day), and late postoperative (6 months). The results showed that there were pregnant differences between preoperative and early on postoperative in Doppler flow parameters (spermatic cord and peak systolic velocity(PSV), terminate diastolic velocity(EDV), and resistivity alphabetize (RI)) (all P < 0.05). There was no significant departure between preoperative and late postoperative values in Doppler menstruation parameters [45].

Compare with different hernias

In Krnic'due south 2022 study (level III_3b), there were a total of 121 patients with an age range of 28–81 years. Group I had 57 patients with non-complicated hernia, and Group 2 had 64 patients with incarcerated hernia. Bard Mesh was used, and the follow-up fourth dimension was 5 months. Resistive index, pulsative alphabetize, and antisperm temporarily fluctuated after the operation, but they returned to or were inside normal values during the late postoperative phase in both groups. This study suggested that polypropylene mesh did not lead to whatever clinically meaning complications on testicular flow in patients under open up hernia repair with either non-complicated or incarcerated hernia [14]. In Ramadan'southward 2009 report (level III_3b), there were a total of 48 patients with indirect inguinal hernia, and the mean age was 44.5 years (range, 30–73 years). The contralateral non-hernia side was set every bit the control group. Testicular arterial impedance, venous plexus period, and testicular perfusion were assessed pre-and postoperatively on both sides, and the follow-up time was 2 months. The results showed that there were no significant changes regarding testicular flow (P > 0.05) [38].

Compare with dissimilar meshes or no mesh

In Hallen'due south 2022 study (level IV₄), from 1992 to 2007, 34,267 men with an age range of 28 to 50 years, underwent an inguinal hernia repair involving at least one side. It was plant that 57 of the 6281 men who underwent the unilaterally without mesh process were diagnosed with infertility. The observed cumulative incidence was 95% CI 0.91 (0.49–0.69) whereas the expected cumulative incidence was one.03. In that location were 133 out of 22,420 men who underwent the unilaterally with mesh procedure that were diagnosed with infertility. The 95% CI of observed cumulative incidence was 0.59 (0.49 to 0.69), and the expected cumulative incidence was 0.67. In the operated bilaterally without mesh group, the infertility incidence was 0/226 where the expected cumulative incidence was i.01. In operated bilaterally with mesh unilaterally grouping, the infertility incidence was 3/346, 95% CI of observed cumulative incidence was 0.87 (0 to xviii.four), and the expected cumulative incidence was i.05. In operated bilaterally with mesh on both sides, the infertility incidence was 19/2293, 95% CI 0.83 (0.46–1.20), and the expected cumulative incidence was 0.64, and in repeated repairs on whatsoever side, the values were 21/2701, 95% (0.45–i.11), and 0.68. The incidence of infertility had no significant change for either the mesh groups or the no-mesh groups. For near groups, the expected cumulative incidence was lower than the general population [32]. In Hallen's 2022 study (level III_3b), the study was based on data from the Swedish Hernia Register and questionnaire. There were a full of 525 participants analyzed. There were 232 in the bilateral mesh repair group with the hateful age of 42.iii ± eight.8 years, 112 in the non-mesh grouping with 43.4 ± eight.viii years, and 181 in the normal population with 43.ane ± 8.1 years. At that place was no substantial effect in testicular condition according to the questionnaire [34].

Open up hernia repair

In this group, these studies were either retrospective, instance series, or case reports.

Yan et al. (level Four₄) performed retrospective analysis for 142 young men under Lichtenstein, and the follow-up time was iii to 36 months. There was no infertility found [18]. Khodari et al. (level Four₄) reported that there were 69 azoospermia patients with a history of developed inguinal hernia repair surgery from 1990 to 2022, but there was no detailed report provided in the assay [19]. Chu et al. examined 4 cases under the inguinal hernia mesh repair with the results showing that testicular ischemia of 2/4 patients was changed, caused past either the mesh loosening or existence removed [37]. Yamaguchi et al. (level Five_v) reported that a thirty year old human being had vas deferens obstacle after inguinal hernia repair with polypropylene mesh within several months [39]. Before azoospermia, men who underwent inguinal herniorrhaphy using polypropylene mesh needed to rapidly cryopreserve their sperm for future fertility; however Testicular / Epididymal Sperm Aspiration or Extraction (TESE-ICSI) was also a suitable treatment. Brisinda et al. (level Four₄) prospectively analyzed 24 patients under open tension-free hernia repair with constructed meshes in 2008 [40]. There were no statistically significant differences found in the testicular blood menstruation parameters and testicular volume comparing preoperative with postoperative. In fact, testicular menses improved in some cases. Dohle et al. (level Five₅) reported two cases of obstructive male infertility due to vassal obstruction after hernia repair with polypropylene mesh. It was believed that polypropylene mesh caused a dense fibroblastic reaction; thus affecting the vas deferens and spermatic cord [41]. Nagler et al. (level 5_v) reported a 45 yr old human experienced obstructive azoospermia after polypropylene mesh repair and a left varicocelectomy. They thought that this issue was influenced by the mesh resulting in fibrosis of the vas deferens [43].

Publication bias

Although at that place were vii RCTs in our report, at that place was no sufficient data included in the studies then the funnel plot, the egger's exam and Begg'southward test were non explored.

Word

Laparoscopic mesh hernia repair group

LAP (included TAPP/TEP) versus open up group

Singh et al. reported that in that location were significant decreases in testosterone, LH, and FSH with less growth in testicular volume under the laparoscopic group; even so there was no significant divergence in testicular atrophy in either the open up repair with polypropylene mesh (heavyweight) or the laparoscopic inguinal hernia repair with polypropylene mesh groups [31]. Akbulut et al. reported that there was no significant divergence in the TEP grouping or the Lichtenstein group in FSH, LH, testosterone, and testicular volume, but TEP may accept decreased testicular volume postal service-operation to the normal limits with blazon I-b, II-a [44]. The diverse results with Singh et al. may have been caused by the pocket-sized sample size, type of hernia, or possibly human error. For example, some TAPP procedures might have been mistakenly placed in the laparoscopic group. Stula et al. reported that mesh hernia repairs under open up tension-gratuitous hernia repair or TAPP were simply changed in the resistive index, terminate diastolic velocity, and peak systolic velocity in the early on postoperative menstruation only returned to a normal value, which they believe has no clinical significance. Notwithstanding, they did non compare the heavyweight against the light heavyweight; instead they only mentioned that the heavyweight mesh was used in the open hernia repair grouping. The age range included was from 17 to 81 years old, then the normal fluctuations might be related with age [27]. This outcome was like to an earlier study published past Stula et al., in 2022 [thirty]. Overall, inguinal hernia mesh repair under open tension-free hernia repair or TAPP did not have clinical significance on testicular flow and immunological response. Thus, these results from the studies indicate that polypropylene mesh LAP inguinal repair did non alter male infertility during either process.

TAPP versus TEP group

Bansal et al. suggested that there was no change in testicular and sexual function after TAPP compared with TEP. Co-ordinate to the publication, changes in male person infertility take no relation to the techniques used for TAPP or TEP; nevertheless they did not mention mesh in the procedures. Rather, the authors thought that handling the testicular vessels and cord structures during dissection may change the etiology of testicular dysfunction later open mesh repair [13].

Dissimilar meshes groups

Peeters et al. indicated that VyproII® or TiMesh® (lightweight mesh) decreased sperm motion when compared to Marlex® mesh (heavyweight) afterward a ane yr follow-up, simply in that location was no significant deviation afterward 3 years. In contrast, the lightweight mesh groups had a lower recurrence rate and no chronic pain, then lightweight mesh could be the superior choice [28, 35]. Junge et al. suggested that using mod low weight, big, porous, and elastic samples could have a benefit on the integrity of the vas deferens, when mesh is the required textile to be used in younger patients undergoing open hernia repair [47].

LAP grouping, no control group

Lal et al. indicated that laparoscopic TEP operations do not alter testicular period dynamics at 24 h, one week, or 3 months postoperative [fifteen]. Skawarn et al. suggested that there was no bear witness of impaired fertility after TEP operation with low-cal or heavy mesh [33]. In that location was no case report found regarding infertility caused past the LAP procedure. The reason backside this is that the LAP procedure allows for less damage and stress to the spermatic string.

Open up mesh hernia repair group

Compare with unlike hernia repair methods

Gvenetadze et al. indicated that the Gvenetadze method was better than Lichtenstein's in preventing male infertility when undergoing open surgery [sixteen]. Kiladze et al. suggested that the Gvenetadze method prevented male infertility though spermatic cord isolation from mesh in bilateral hernia procedures compared to the Lichtenstein hernia repair [37]. Contrarily, Sucullu et al. and Aydede et al. indicated that whether the Lichtenstein, mesh plug method, posterior pre-peritoneal mesh repair, or anterior tension-free repair were used, none of the procedures caused infertility. Thus, it seems that numerous hernia repair methods which are performed routinely in the dispensary do non pb to infertility [35, 42, 45].

Compare different hernias

Krnic et al. reported that 57 patients had non-complicated hernia procedures whereas 64 patients with incarcerated hernia. Bard Mesh was used in both groups. This study suggested that polypropylene mesh did not lead to any clinically significant problems on testicular flow in patients undergoing open hernia repair with either non-complicated or incarcerated hernia [14]. In the Ramadan et al. written report, it showed that there was no significant change to testicular menstruation in the hernia side vs. non-hernia side; thus, different types of hernias may non impact infertility under the open up hernia repair with mesh [38].

Compare with meshes with no mesh

Hallen et al. performed an epidemiological survey in 2022, 232 in the bilateral mesh repair group and 112 in the non-mesh group were analyzed. There were no noteworthy furnishings in the testicular status of either group, according to the questionnaire. The authors believed that local legal circumstances and health care policies should exist taken into consideration when doing sperm cryopreservation and the health intendance system should cover the price of this fee if immature men wish to have children after on in life [34]. The following year, Hallen et al. started a larger epidemiological survey where 0.9% (57/6281) of men were diagnosed with infertility after being operated on unilaterally without mesh compared to 0.59% (133/22420) of men with mesh. In the operated bilaterally, mesh on one side group, the infertility incidence was 0.87% (3/346). In operated bilaterally, mesh on both sides grouping, the incidence was 0.83% (nineteen/2293) and in repeated repairs on any side, there was 0.77% (21/2701). The results showed that the incidence of infertility had no result in either the mesh groups with no-mesh groups, and mesh repair may continue to be used without major business organization regarding the risk of male infertility [32].

Open hernia repair

In this group, these studies were retrospectives, case series, or example reports. Yan et al. and Brisinda et al. reported that there was no prove that indicated that infertility was caused by the Lichtenstein or open tension-free hernia procedure [18, twoscore]. Khodari et al. mentioned that at that place were 69 azoospermia patients with a history of undergoing adult inguinal hernia repair surgery but did non describe the causes for the azoospermia [19]. Nagler et al. considered that a case with azoospermia was acquired by mesh due to fibrosis of the vas deferens [43]. Yamaguchi et al. and Dohle et al. reported three cases with vas deferens obstruction afterward inguinal hernia repair with polypropylene mesh [39, 41]. Uzzo et al. reported in a 12 male beagle dog animal trial where half of the dogs were repaired using Marlex mesh and one-half had the classic Shouldice technique. At that place was a significant decrease in vasal luminal size with a marked soft tissue foreign body reaction identified in the Marlex mesh group [48].

Why could this change in process atomic number 82 to infertility? There may be a relationship with mesh migration, surgeon skills, tightness of intraoperative suture or the surrounding tissue was not completely separated. The resulting postoperative bleeding, adhesions, and postoperative exercise frictions then trigger fibrosis which can lead to infertility. Chu et al. (level IV₄) reported 2 cases of testicular ischemia that were altered under inguinal hernia mesh repair, caused by the mesh loosening or removal [37]. Although there are fewer reports on vas deferens blockage, we still should focus on the standardization for operative procedures in order to lessen and ultimately, eliminate postoperative complications from the treatment. Some other reason behind the cause of these medical concerns could be due to the level of the surgeon's skill. For case, if the blood vessels were damaged during the intraoperative operation, information technology would pb to vas deferens ischemia, which could cause infertility. Some cases that are diagnosed as infertility may be associated instead with the inguinal hernia. Singh et al. indicated that long term inguinal hernia patients might suffer from impairment in testicular blood flow, which could too pb to infertility [31]. Boosted factors that could affect infertility could include the patient'southward age, piece of work status, psychological factors, and the environment. Previously, our creature studies suggested that the distribution of inguinal hernia may be related to estrogen levels, and these estrogen levels may be associated with infertility. Aydede et al. suggested that mesh repair is all the same a rubber surgery in patients with no children or those who are currently undergoing infertility treatment [45]; only in our opinion, if a young man desires to have children in the future and is humble about potential issues to his fertility due to the surgical procedure, he should have his semen examined and stored preoperatively to avert time to come problems and medical disputes.

The major limitations of our study were the following: 1) there was loftier clinical heterogeneity between the included RCTs, 2) in that location were pocket-size samples for these included studies, and three) the catamenia of handling for each study and mesh were different. For some of these studies, in that location was bereft data provided for meta-assay, and the show was weak, so funnel plot and meta-analysis were non performed. That will lead to some publication bias and less potent evidence. Larger samples, rigorous design, multi-eye RCTs performed using diverse populations, and dissimilar mesh/intervention groups would be necessary to heighten this evidence and support a stronger conclusion regarding infertility in these procedures.

Determination

The results of our review propose that open or laparoscopic procedures with mesh hernia repair have no significant effects on male person infertility according to the current RCTs and clinical trials (Evidence: level I). Overall, laparoscopic mesh repair might be more suitable to employ for preserving testicular functions; however our main focus should be on standardizing operative procedures in gild to lessen or eliminate postoperative complications.

Acknowledgments

Nosotros thank Dr. Soper for helping to review and providing advice in regards to the manuscript.

Abbreviations

ASA	Anti-sperm antibodies
ATCR	Australian New Zealand Clinical Trials Registry
CBM	Chinese biomedical medicine database
CCTR	Chinese clinical trial register
Central	Cochrane Library hosts the Central Register of Controlled Trials
EDV	Terminate diastolic velocity
EDV	End-diastolic velocity
FSH	Follicle-stimulating hormone
ISRCTN	International Standard Randomized Controlled Trial Number Annals
LH	Luteinizing hormone
LHR	Lichtenstein hernia repair
mU	α-glucosidase
PI	Pulsatility index
PSV	Superlative systolic velocity
RCT	Randomized controlled trials
RI	Resistivity index
TAPP	laparoscopic transabdominal preperitoneal hernia repair
TC	Trials Central
TEP	Totally actress-peritoneal repair
TESE-ICSI	Testicular / Epididymal Sperm Aspiration or Extraction
WHOITRP	World Wellness Organization International Trials Registry Platform search portal

Authors' contributions

ZH and CW designed and reviewed the study. ZD, SK and CW nerveless data, conducted analysis and wrote the manuscript. All authors read and approved the final manuscript.

Notes

Ethics approving and consent to participate

Not applicable. This article is a systematic review and descriptive assay, then no ethical board approval is needed.

Competing interests

The authors declare that they have no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Data

Cunchuan Wang, Phone: +86 twenty 38688608, Email: moc.361@5102ccwt.

Hong Zhao, Phone: 312-503-0780, Email: ude.nretsewhtron@oahz-h.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914038/

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