Surgery or embolisation for varicocele in subfertile men

Feasibility of loupe assisted subinguinal varicocelectomy in treatment of male infertility

OBJECTIVES

To study the impact of loupe assisted subinguinal varicocelectomy on semen quality, serum testosterone level, and spontaneous pregnancy rate.

METHODS

The data were prospectively collected for 102 infertile men with clinical varicocele. The preoperative values of semen analysis parameters and serum testosterone level were compared with postoperative values at 6 months. Spontaneous pregnancy was assessed at 6 months.

RESULTS

The mean age of patients was 31.56 ± 4.31 years. Primary infertility was reported in 86 patients, while 16 had secondary infertility. Bilateral varicocele was seen in 79 patients while 23 had a unilateral varicocele. The total sperm concentration (×10⁶/mL) before and after varicocelectomy was 12.82 ± 3.91 and 20.06 ± 2.13 respectively (P < .0001). The total sperm motility (%) before and after varicocelectomy was 37.67 ± 7.23 and 55.46 ± 4.51 respectively (P < .0001). The sperm morphology (Kruger/Strict morphology criteria, %) before and after varicocelectomy was 3.11 ± 0.80 and 3.70 ± 0.78 respectively (P < .0001). The serum testosterone level (ng/dL) before and after varicocelectomy was 323.90 ± 67.81 and 396.74 ± 40.88 respectively (P < .0001). The Spontaneous pregnancy rate in couples with primary and secondary infertility was 18.60% and 31.25% respectively. The difference in their rates was not significant (P = .251). The overall spontaneous pregnancy rate was 20.5%.

CONCLUSION

Loupe-assisted sub-inguinal varicocelectomy is a safe and effective modality for treating infertile men, particularly when provision for microscopic surgery is unavailable. However, only large size comparative studies or multi-centric trials can confirm this.

Improvement of semen parameters after coil embolization of varicoceles: a systematic review

This systematic review was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, including clinical studies in which one of the outcomes was semen parameter improvement after varicocele embolization using coils only. The objective of the review was to assess the evidence on the role of embolization using coils alone for semen parameter improvement in men with varicocele, since embolization using coils is the most cost-effective method of varicocele repair. Study quality was assessed using the methodological index for non-randomized studies (MINORS). Out of six retrospective and two prospective observational or comparative clinical studies involving 701 patients, semen concentration improved significantly in all five studies that assessed this parameter. Mean semen motility improved significantly in seven studies. The impact of embolization on semen density could not be analyzed.

[Favorable impact of left antegrade sclerotherapy of clinical left varicocele on spermogram]

OBJECTIVES

Study the early postoperative course of sperm parameters after antegrade sclerotherapy (AS) of clinical left varicocele (CLV) in men consulting for infertility with sperm disruption, and to validate the efficacy and safety of treatment.

MATERIALS AND METHODS

Monocentric retrospective observational study of men with CLV, consultant in medically assisted procreation center for primary or secondary infertility of the couple. All patients were operated by SA via scrotal approach. After clinical and ultrasound checks at 6 weeks, a control spermogram was performed at 3-6 months of surgery. The following parameters were analyzed: sperm count, motility, percent of normal form, and total number of motile sperm ("total motile sperm count" [TMSC]).

RESULTS

The study involved 138 men (median age 33 years) with sperm alteration. All patients benefited from AS of their CLV. No Clavian complication > 1 was observed. Postoperative control demonstrated a significant improvement in all spermogram parameters, with a median progression of 40% of the count (55 vs 32×106), 80% of the concentration (20.3 vs 11.1×106/ml), 30% of the motility (34.7% vs 26.5%), 60% of the normal form percentage (4.0 vs 2.5%) and the 75% TMSC (41.5 vs 23%), 7×106) (p<0.005).

CONCLUSIONS

SA is an effective and safe technique for treating CLV and improving sperm parameters fertility indicators. Our results suggest that this treatment may be recommended to infertile men with CLV in the management of infertility of the couple.

LEVEL OF EVIDENCE

3.

Should the current guidelines for the treatment of varicoceles in infertile men be re-evaluated?

Male infertility is a major health burden worldwide. In the United Kingdom, the diagnostic and treatment pathway for male factor fertility is fragmented with wide variance in management and funding protocols. There is now a focus on potential overtreatment of couples with IVF and failure to treat male factors before considering assisted reproductive technology (ART). Despite this, contemporary Urological guidelines are not definitive in the indications for varicocele treatment, whilst the current National Institute for Health and Care Excellence (NICE) guidelines do not advocate surgical intervention. While controversy exists concerning the effects of varicocele treatment on natural pregnancy rates, there is growing evidence that varicocele treatment can have additional positive effects on fertility by reducing their impact on sperm DNA fragmentation and improving ART outcomes. Studies have demonstrated that azoospermic men may become oligospermic following varicocele intervention, obviating the need for surgical sperm retrieval. Sperm retrieval rates also increase following varicocele treatment in men with non-obstructive azoospermia. The contemporary literature demonstrates a clear clinical benefit for treating varicoceles in infertile men, which may be more cost-effective than proceeding to immediate ART. This review comprehensively evaluates the current indications for varicocele treatment, and it is proposed that these should be redefined in contemporary guidelines to reflect current advances in male fertility research.

Should primary microsurgical ligation of varicocele be the gold standard approach?

Introduction:

Varicocele is a common condition affecting over one in 10 men, and in cases with abnormal semen parameters, varicocele is present in about one in four men. Several methods have been used to treat this condition, of which microsurgical treatment has the lowest failure and complication rates. We present a single-centre UK series of microsurgical repair of varicocele.

Methods:

All microsurgical varicocelectomy cases performed between 2013 and 2017 were retrospectively identified and reviewed. The approach used is low inguinal using a high-powered Leica microscope.

Results:

Microsurgical varicocele repairs were performed in 30 cases, with a median age of 34.7 years. There were 22 cases with chronic scrotal pain of which eight cases had failed previous embolisation with a success rate of 90.5%. There were eight with oligoasthenoteratozoospermia, showing an improvement of more than 75% in sperm count after repair.

Conclusions:

Microsurgical ligation is a very effective treatment for symptomatic varicoceles and should be considered when radiological embolisation has failed. It is also effective in improving semen parameters in all followed up oligoasthenoteratozoospermia cases. It should be considered a primary method of varicocele treatment in the UK.

Level of evidence:

3.

The Role of Varicocele in Male Factor Subfertility

PURPOSE OF REVIEW

Varicocele may play a significant role in a subset of patients presenting with male factor infertility. Despite its relatively high prevalence amongst subfertile men, there has been controversy over the effectiveness of surgical treatments, patient selection, and when to administer treatment, particularly in the era of assisted reproductive technology.

RECENT FINDINGS

In line with earlier finding, recent evidence strongly suggests that varicocelectomy improves pregnancy rates and semen parameters. The currently available literature still does not clearly elucidate the answer to this question, due to flaws in retrospective study design. Patients undergoing subinguinal microsurgical varicocelectomy appear to have the highest pregnancy rates, and lowest complication rates, compared to other surgical approaches. Current research has given us a better understanding of the relationship between varicocele and infertility. Amongst men presenting with semen analysis abnormalities and varicoceles, including those patients presenting with non-obstructive azoospermia or couples with a significant male factor component failing previous attempts at in vitro fertilization, varicocelectomy may improve take home baby rates. More robust, prospective, controlled studies are needed to further clarify the population of subfertile men with varicocele most likely to benefit from varicocelectomy.

Varicocele management for infertility and pain: A systematic review

Despite being first described two thousand years ago, the varicocele remains a controversial multifaceted disease process with numerous biological consequences including infertility, hypogonadism, and chronic orchidalgia. The underlying mechanisms remain poorly understood and likely include hypoxia, oxidative stress, hyperthermia, anatomical aberrations, and genetics as primary components. Despite a high prevalence amongst asymptomatic fertile men, varicoceles paradoxically also represent the most common correctable cause for male infertility. In this systematic review we discuss the rich historical aspects of the varicocele and the contemporary data regarding its clinical manifestations. We performed a systematic literature review with the goal of comparing outcomes and complication rates of each of the major surgical approaches as they relate to infertility and pain. We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-compliant systematic literature review for manuscripts focused on varicocele and its biological consequences. We identified 112 studies suitable for qualitative analysis and included 56 of these for quantitative analysis, with an emphasis on infertility and chronic pain outcomes. Taken together, the clinical work to date suggests that the highest fertility rates and the lowest complication rates are associated with the microsurgical subinguinal surgical approach to varicocelectomy. In all, 26-40% of patients undergoing varicocelectomy will successfully achieve short-term spontaneous pregnancy, and up to 90% of all patients undergoing varicocelectomy for pain will have improvement and/or resolution of their symptoms. Taken together, the data support an ongoing role for varicocelectomy in both of these clinical arenas.

Retroperitoneal Varix ligation with sclerotherapy: a prospective randomized comparative study

Introduction

The aim of this article is to compare the results of high varix ligation with and without sclerotherapy.

Material and methods

Between November 2014 and December 2015, sixty patients with varicocele were included in this study. Patients were divided into two equal groups; group I (underwent high varix ligation), and group II (underwent high varix ligation with a retrograde injection of 2 mL of 5% ethanolamine oleate in the lower end of the bisected gonadal vein). The operative time, intra- and postoperative complications, postoperative pain, improvement of semen parameters, incidence of recurrence and achieving of unassisted pregnancy were recorded for both groups.

Results

The age range was 19-34 years in group I and 21-37 years in group II. The operative time was shorter in group I (34.6 ±7.81 min) than group II (43.3 ±8.5 min) (P <0.001), which was statistically significant.Improvement of semen parameters and the occurrence of spontaneous pregnancy were insignificant between both groups. No intraoperative complications occurred. The postoperative complications were statistically insignificant in both groups.

Conclusions

Combined varix ligation with retrograde sclerotherapy does not offer significant advantages over high varix ligation alone with a longer operative time and prolonged post-operative pain.

Subinguinal microsurgical varicocelectomy vs. percutaneous embolization in infertile men: Prospective comparison of reproductive and functional outcomes

Background

Varicocele is a condition characterized by dilated, tortuous veins within the pampiniform venous plexus of the scrotal sac. Presence of varicocele is associated with an increased risk of alteration of semen parameters. The objective of this study was to compare the current standard in varicocele treatment procedures: sub-inguinal microscopic ligation to percutaneous embolization in terms of semen parameters improvement, fertility, and morbidity at the university hospital of Toulouse (France). Seventy six patients with clinical varicocele, alteration of semen parameters and infertility, underwent either procedure (microsurgery in 49 case performed by a single surgeon and embolization in 27 cases) and were prospectively analyzed. Outcome measures were: semen parameters, spontaneous pregnancies, pain, side effects, recovery time and overall satisfaction. All patients were contacted in January 2015 in order to determine reproductive events.

Results

Preoperatively, there was no difference in clinical and biological items between the two groups. Postoperatively, on the overall population, there was a significant improvement of sperm concentration at 3, 6, 9 and 12 months (p = <0.001, <0.001, 0.012, 0.018) and sperm motility at 6 months (p = 0.002). The sperm concentration was higher at 6 months in the percutaneous embolization group (13.42, vs. 8.1×10⁶/ml; p = 0.043). With a median follow-up of 4 years, 27 pregnancies occurred (spontaneous pregnancy rate of 35.5%).

There was no significant difference between procedures on the sperm quality, pregnancy rate, and the overall satisfaction. Patients undergoing percutaneous embolization reported a faster recovery time (p = 0.002) and less postoperative pain (p = 0.007).

Conclusion

Our study shows that percutaneous embolization seems to be an equivalent alternative to sub-inguinal microscopic ligation in term of sperm quality improvement, pregnancy rate, and overall satisfaction with a slight advantage on post-operative morbidity.

Semen parameters and pregnancy rates after microsurgical varicocelectomy in primary versus secondary infertile men

In a prospective study, the outcomes of microsurgical varicocelectomy in men with primary versus secondary infertility were compared. Ninety-two infertile men with a varicocele were included. They were classified into those with primary infertility (n = 57) and secondary infertility (n = 35). Clinical data, semen parameters and scrotal ultrasound finding were available for all patients and microsurgical varicocelectomy was performed on all of them. Spontaneous pregnancy rates and improvement in semen parameters in those men with primary versus secondary infertility were recorded 1 year after surgery. Preoperatively, there was no significant difference in the mean semen parameters in both groups (p > 0.05) and the mean semen parameters showed no significant difference between men with primary and secondary infertility. After microsurgical varicocelectomy, the mean semen parameters improved significantly in both group (p < 0.05 for each), but there were no significant difference in mean semen parameters between men with primary versus secondary infertility (p > 0.05 for each). After adjustment for patient and partner ages, the pregnancy rate at the end of the follow-up period did not significantly differ between the primary (24/57, 42.1%) and secondary (11/35, 31.4%) infertility group (Pearson's Chi-squared = 1.05). We concluded from this study that semen parameters and pregnancy rates after microsurgical varicocelectomy were similar between men with primary and secondary infertility.

Surgical management of male infertility: an update

Male factor infertility is common, affecting 7% of the total population and up to half of couples who are trying to conceive. Various surgical and reconstructive options allow biological paternity depending on the etiology of the male factor issues. This article describes historical treatments and newer approaches, discussing the role for traditional open surgery, microsurgery and robotic surgery, as well as interventional radiologic procedures in the management of male infertility.

Varicocele as a source of male infertility - current treatment techniques

To establish the extent of varicocele as the cause of infertility in men and compare the various techniques of treatment. We searched PubMed and the Cochrane Library database using varicocele, male infertility, varicocelectomy as keywords. Varicocele seems to be a growing problem considered to be one of the most common causes of male infertility in recent times. Nevertheless, its role remains unclear. The best treatment option seems to be microscopic surgery - the most effective and linked to rare surgical complications. But the greatest clinical problem remains the selection of patients to treat - recently it is believed that varicocelectomy is a possibly advisable option in patients with clinical varicocele and seminal parameter impairment [1]. More high-quality, multicenter, long-term randomized controlled trials (RCT's) are required to verify the findings.

Traditional Chinese Herb Combined with Surgery versus Surgery for Varicocele Infertility: A Systematic Review and Meta-Analysis

Objective. The objective of this study was to conduct a systematic review to assess the effectiveness and safety of traditional Chinese herb combined with surgery for male varicocele infertility compared to surgery. Methods. Randomized controlled trials (RCTs) data of traditional Chinese herbs combined with surgery for male varicocele fertility versus surgery were collected by searching the Cochrane Library, Embase, PubMed, and Chinese databases. The risk of bias was assessed using Cochrane Handbook. Study outcomes were presented as risk ratios (RRs) for dichotomous data. Results. Seventeen of 72 potentially relevant trials met the inclusion criteria. The methodological qualities of the RCTs were low. Compared with the surgery group, the traditional Chinese herb combined with surgery group had superiority in pregnancy rate at 3-month (RR = 1.76, and P = 0.008), 6-month (RR = 1.58, and P = 0.0005), and 2-year (RR = 1.58, and P = 0.0005) follow-ups. No RCT was found to describe the side effects. Conclusion. On considering the low methodological quality of RCTs, there was no enough evidence on traditional Chinese herb with surgery for male varicocele infertility, and more high-quality RCTs of large sample sizes are required.

Effect of varicocelectomy on male infertility

Varicocele is the most common cause of male infertility and is generally correctable or at least improvable by various surgical and radiologic techniques. Therefore, it seems simple and reasonable that varicocele should be treated in infertile men with varicocele. However, the role of varicocele repair for the treatment of subfertile men has been questioned during the past decades. Although varicocele repair can induce improvement of semen quality, the obvious benefit of spontaneous pregnancy has not been shown through several meta-analyses. Recently, a well-designed randomized clinical trial was introduced, and, subsequently, a novel meta-analysis was published. The results of these studies advocate that varicocele repair be regarded as a standard treatment modality in infertile men with clinical varicocele and abnormal semen parameters, which is also supported by current clinical guidelines. Microsurgical varicocelectomy has been regarded as the gold standard compared to other surgical techniques and radiological management in terms of the recurrence rate and the pregnancy rate. However, none of the methods has been proven through well-designed clinical trials to be superior to the others in the ability to improve fertility. Accordingly, high-quality data from well-designed studies are needed to resolve unanswered questions and update current knowledge. Upcoming trials should be designed to define the best technique and also to define how to select the best candidates who will benefit from varicocele repair.

Impact of surgical varicocele repair on pregnancy rate in subfertile men with clinical varicocele and impaired semen quality: a meta-analysis of randomized clinical trials

Purpose

To elucidate the impact of surgical varicocele repair on the pregnancy rate through new meta-analyses of randomized clinical trials that compared surgical varicocele repair and observation.

Materials and Methods

The PubMed and Embase online databases were searched for studies released before December 2012. References were manually reviewed, and two researchers independently extracted the data. To assess the quality of the studies, the Cochrane risk of bias as a quality assessment tool for randomized controlled trials was applied.

Results

Seven randomized clinical trials were included in our meta-analyses, all of which compared pregnancy outcomes between surgical varicocele repair and control. There were differences in enrollment criteria among the studies. Four studies included patients with clinical varicocele, but three studies enrolled patients with subclinical varicocele. Meanwhile, four trials enrolled patients with impaired semen quality only, but the other three trials did not. In a meta-analysis of all seven trials, a forest plot using the random-effects model showed an odds ratio (OR) of 1.90 (95% confidence interval [CI], 0.77 to 4.66; p=0.1621). However, for subanalysis of three studies that included patients with clinical varicocele and abnormal semen parameters, the fixed-effects pooled OR was significant (OR, 4.15; 95% CI, 2.31 to 7.45; p<0.001), favoring varicocelectomy.

Conclusions

Varicocelectomy for male subfertility is proven effective in men with clinical varicocele and impaired semen quality. Therefore, surgical repair should be offered as the first-line treatment of clinical varicocele in subfertile men.

The role of varicocele treatment in the management of non-obstructive azoospermia

The literature on male reproductive medicine is continually expanding, especially regarding the diagnosis and treatment of infertility due to non-obstructive azoospermia. The advent of in vitro fertilization with intracytoplasmic sperm injection has dramatically improved the treatment of male infertility due to nonobstructive azoospermia. Assisted reproduction using testicular spermatozoa has become a treatment of hope for men previously thought to be incapable of fathering a child due to testicular failure. In addition, numerous studies on non-obstructive azoospermia have reported that varicocelectomy not only can induce spermatogenesis but can also increase the sperm retrieval rate; however, the value of varicocelectomy in patients with non-obstructive azoospermia still remains controversial. The purpose of this review is to present an overview of the current status of varicocele repair in men with non-obstructive azoospermia.

Recruitment challenges of a multicenter randomized controlled varicocelectomy trial

OBJECTIVE

To review reasons for suboptimal recruitment for a randomized controlled trial (RCT) of varicocelectomy versus intrauterine insemination (IUI) for treatment of male infertility and to suggest means for improving future study recruitment.

DESIGN

Survey of Reproductive Medicine Network (RMN) participating sites.

SETTING

Reproductive Medicine Network.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ascertain reasons for inadequate recruitment and suggest improvements for future varicocelectomy trails.

RESULT(S)

This study screened seven and enrolled three couples, with the first couple randomized on June 30, 2010. The study was subsequently stopped on March 30, 2011. The following themes were cited most frequently by sites and therefore determined to be most likely to have played a role in suboptimal recruitment: [1] men must be screened at the beginning of a couple's infertility evaluation, [2] inclusion of infertile women who had failed previous fertility interventions appeared to be associated with the couple's intolerance of a placebo arm, and [3] an apparent bias against the use of unstimulated IUI cycles indicated a prejudicial preference for surgical intervention in the male partner.

CONCLUSION(S)

Improved recruitment may be realized through screening infertile men as early as possible while minimizing study-related time commitments. Focused patient education may promote improved equipoise and acceptance of a placebo arm in male infertility studies. Creative approaches to implementing varicocelectomy trials must be considered in addition to having a network of motivated researchers who carry a high volume of possible study participants because very large numbers may need to be screened to complete the clinical trial enrollment.

A critical appraisal on the role of varicocele in male infertility

Varicocele is a major cause of male infertility, as it may impair spermatogenesis through several distinct physiopathological mechanisms. With the recent advances in biomolecular techniques and the development of novel sperm functional tests, it has been possible to better understand the mechanisms involved in testicular damage provoked by varicocele and, therefore, propose optimized ways to prevent and/or reverse them. Up to now, there is still controversy involving the true benefit of varicocele repair in subfertile men as well as in certain specific situations such as concomitant contralateral subclinical varicocele or associated nonobstructive azoospermia. Also, with the continued development of assisted reproductive technology new issues and questions are emerging regarding the role of varicocelectomy in this context. This paper reviews the most recent data available on the pathogenesis, diagnosis, and management of varicocele with regard to male infertility.

Effect of age on semen parameters in infertile men after varicocelectomy

Background

The effectiveness of varicocelectomy in restoration of fertility and improvement of semen parameters is still controversial. The purpose of this study was to determine the effect of age on semen parameters following varicocelectomy in a group of infertile men.

Methods

Improvements in sperm count, morphology, and motility were studied in 67 infertile patients 4–10 months after varicocelectomy.

Results

The mean age of the patients was 30.48 ± 7.49 years. Significant improvements in total sperm count, percentage normal morphology, and motility were noted in all age groups (P < 0.05). Patients aged <25 years demonstrated the greatest increase in sperm counts, normal morphology, and motility following varicocelectomy. There was a significant negative correlation between age and sperm count, sperm morphology, and sperm motility (P < 0.05).

Conclusion

The effect of age on improvement in sperm parameters after varicocelectomy is inconsistent with some reports in the literature, and could be attributable to the duration of infertility prior to surgery; in the long term, varicoceles are known to have deleterious effects on testis biology.

The role of varicocele sclerotherapy in men with severe oligo-astheno-teratozoospermia

The aim of this study was to verify the role of antegrade scrotal sclerotherapy for the treatment of varicoceles in infertile men with severe oligo-astheno-teratozoospermia (OAT). The 59 patients with severe OAT in this study underwent antegrade scrotal sclerotherapy for the treatment of varicoceles. The outcome was assessed in terms of improvement in semen parameters and spontaneous conception rate. Semen parameters and reproductive hormones were evaluated before antegrade sclerotherapy (AS) and 6 months after AS. After an average follow-up time of 34.8±3.2 months, significant improvement was noted in the mean sperm concentration, motility and morphology in 36 patients (61%). Spontaneous pregnancy occurred in nine couples (15%). Six months after treatment, inhibin B levels were significantly higher (P<0.04), whereas follicle-stimulating hormone (FSH) levels were significantly lower (P<0.001) than before treatment. Antegrade internal spermatic vein sclerotherapy can significantly improve seminal parameters and hormonal parameters in men with severe OAT and may even result in spontaneous pregnancy in couples who would otherwise be candidates for intracytoplasmic sperm injection (ICSI).

Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair

CONTEXT

Varicocele is a common condition, found in many men who present for infertility evaluation.

OBJECTIVE

To assess the effect of varicocelectomy on male infertility.

EVIDENCE ACQUISITION

A literature search was performed using Embase and Medline. Literature reviewed included meta-analyses and randomized and nonrandomized prospective (controlled and noncontrolled) studies. In addition, a new meta-analysis was performed.

EVIDENCE SYNTHESIS

Four randomized controlled trials reporting on pregnancy outcome after repair of clinical varicoceles in oligozoospermic men were identified. Using the random effect model, the combined odds ratio was 2.23 (95% confidence interval [CI], 0.86-5.78; p=0.091), indicating that varicocelectomy is moderately superior to observation, but the effect is not statistically significant. We identified 22, 17, and 5 prospective studies reporting on sperm concentration, total motility, and progressive motility, respectively, before and after repair of clinical varicocele. The random effect model combined improvement in sperm concentration was 12.32 million sperm per milliliter (95% CI, 9.45-15.19; p<0.0001). The random effect model combined improvement in sperm total and progressive motility were 10.86% (95% CI, 7.07-14.65; p<0.0001) and 9.69% (95% CI, 4.86-14.52; p=0.003), respectively. These results indicate that varicocelectomy is associated with a significant increase in sperm concentration as well as total and progressive motility. Prospective studies also show that varicocelectomy reduces seminal oxidative stress and sperm DNA damage as well as improving sperm ultramorphology. Studies indicate that a microsurgical approach to a varicocele repair results in less recurrence and fewer complications than other techniques.

CONCLUSIONS

Although there is no conclusive evidence that a varicocele repair improves spontaneous pregnancy rates, varicocelectomy improves sperm parameters (count and total and progressive motility), reduces sperm DNA damage and seminal oxidative stress, and improves sperm ultramorphology. The various methods of repair are all viable options, but microsurgical repair seems to be associated with better outcomes.

Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial

BACKGROUND

Randomized controlled trials (RCTs) addressing varicocele treatment are scarce and have conflicting outcomes.

OBJECTIVE

To determine whether varicocele treatment is superior or inferior to no treatment in male infertility from an evidence-based perspective.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, nonmasked, parallel-group RCT with a one-to-one concealed-to-random allocation was conducted at the authors' institution from February 2006 to October 2009. Married men 20-39 yr of age who had experience infertility ≥1 yr, had palpable varicoceles, and with at least one impaired semen parameter (sperm concentration <20 million/ml, progressive motility <50%, or normal morphology <30%) were eligible. Exclusions included subclinical or recurrent varicoceles, normal semen parameters, and azoospermia. Sample size analysis suggested 68 participants per arm.

INTERVENTION

Participants were randomly allocated to observation (the control arm [CA]) or subinguinal microsurgical varicocelectomy (the treatment arm [TA]). Semen analyses were obtained at baseline (three analyses) and at follow-up months 3, 6, 9, and 12. The mean of each sperm parameter at baseline and follow-ups was determined.

MEASUREMENTS

We measured the spontaneous pregnancy rate (the primary outcome), changes from baseline in mean semen parameters, and the occurrence of adverse events (AE-the secondary outcomes) during 12-mo follow-up; p<0.05 was considered significant.

RESULTS AND LIMITATIONS

Analysis included 145 participants (CA: n=72; TA: n=73), with a mean age plus or minus standard deviation of 29.3±5.7 in the CA and 28.4±5.7 in the TA (p=0.34). Baseline characteristics in both arms were comparable. Spontaneous pregnancy was achieved in 13.9% (CA) versus 32.9% (TA), with an odds ratio (OR) of 3.04 (95% confidence interval [CI], 1.33-6.95) and a number needed to treat (NNT) of 5.27 patients (95% CI, 1.55-8.99). In CA within-arm analysis, none of semen parameters revealed significant changes from baseline (sperm concentration [p=0.18], progressive motility [p=0.29], and normal morphology [p=0.05]). Conversely, in TA within-arm analysis, the mean of all semen parameters improved significantly in follow-up versus baseline (p<0.0001). In between-arm analysis, all semen parameters improved significantly in the TA versus CA (p<0.0001). No AEs were reported.

CONCLUSIONS

Our RCT provided level 1b evidence of the superiority of varicocelectomy over observation in infertile men with palpable varicoceles and impaired semen quality, with increased odds of spontaneous pregnancy and improvements in semen characteristics within 1-yr of follow-up.

Report on varicocele and infertility

Controversies regarding diagnosis and treatment of varicoceles in male partners in infertile couples are considered in detail.

Embolization of varicocles: pretreatment sperm motility predicts later pregnancy in partners of infertile men

PURPOSE

To identify predictors of future pregnancy in partners of infertile men undergoing embolization of varicoceles.

MATERIALS AND METHODS

This study was conducted within local institutional review board guidelines, and written informed consent was obtained. In 223 clinically infertile men (age range, 18-50 years) with varicoceles and associated oligoteratoasthenospermia, endovascular embolization of the spermatic veins was performed with distal coil embolization and sclerotherapy. Additional anti-inflammatory treatment was initiated if required. Baseline clinical examination, semen specimen, and hormone level findings were compared to follow-up data. Posttreatment pregnancy rate of their healthy female partners was assessed with a standardized questionnaire. Unconditioned logistic regression was used to identify factors among all available clinical and laboratory data predicting treatment success (sired pregnancy during follow-up).

RESULTS

A total of 226 of 228 varicoceles in 223 patients were successfully treated. Resolution of varicoceles at clinical examination and ultrasonography (US) was observed in 206 patients (92.4%). Three-month follow-up semen analysis in these patients showed significant improvement in sperm motility (P < .001) and sperm count (P < .001); however, average values remained in the abnormal range (World Health Organization guidelines). In 173 patients, follow-up data were successfully obtained, with pregnancy reported in 45 (26%). Baseline sperm motility was identified as the only significant pretreatment factor (standardized regression coefficient beta = 3.285, t = 7.560, P = .006) predicting sired pregnancy. Hormone levels, clinical grading of varicoceles, Doppler US findings, and other semen parameters did not reach statistical significance.

CONCLUSION

Sperm motility prior to varicocele treatment in infertile men is an important predictor of later pregnancy.

Improvement of seminal parameters and pregnancy rates after antegrade sclerotherapy of internal spermatic veins

OBJECTIVE

To evaluate the impact of antegrade scrotal sclerotherapy on seminal parameters and pregnancy rates in varicocele patients who have impairment of seminal parameters and/or couple infertility.

DESIGN

Longitudinal, noncomparative study.

SETTING

Tertiary university hospital.

PATIENT(S)

Three hundred sixty-four consecutive varicocele patients with seminal impairment, including 173 (47.5%) patients who were not interested in fertility and 191 (52.5%) who were infertile.

INTERVENTION(S)

Modified antegrade scrotal sclerotherapy.

MAIN OUTCOME MEASURE(S)

Increase in sperm count, motility, and/or normal forms in all patients. Pregnancy rates 12 months after treatment in infertile men.

RESULT(S)

The median patient age was 32 years. Twelve months after treatment, persistent reflux was present in 45 (12.4%) cases. In 188 (51.6%) patients with low sperm number, sperm count statistically significantly improved, from 12 to 19.5 x 10(6) per milliliter. In the 336 (92.3%) patients with asthenospermia, progressive motile forms statistically significantly improved, from 25% to 45%. In the 147 (40.4%) patients with teratospermia, normal forms increased from 17% to 35%. In infertile patients without persistent varicocele, 65 (37.4%) patients fathered offspring. Patients obtaining a pregnancy presented a significantly higher sperm motility than did infertile patients (46% vs. 35%).

CONCLUSION(S)

Antegrade scrotal sclerotherapy significantly improves sperm count, motility, and morphology. Patients with couple infertility achieved a pregnancy in 37% of cases. Patients achieving pregnancy present a better progressive motility after treatment than patients who did not father any child.

Oxidative stress and male infertility--a clinical perspective

Oxidative stress occurs when the production of potentially destructive reactive oxygen species (ROS) exceeds the bodies own natural antioxidant defenses, resulting in cellular damage. Oxidative stress is a common pathology seen in approximately half of all infertile men. ROS, defined as including oxygen ions, free radicals and peroxides are generated by sperm and seminal leukocytes within semen and produce infertility by two key mechanisms. First, they damage the sperm membrane, decreasing sperm motility and its ability to fuse with the oocyte. Second, ROS can alter the sperm DNA, resulting in the passage of defective paternal DNA on to the conceptus. This review will provide an overview of oxidative biochemistry related to sperm health and will identify which men are most at risk of oxidative infertility. Finally, the review will outline methods available for diagnosing oxidative stress and the various treatments available.

Sperm count and sperm motility in incidental high-grade varicocele

One hundred twenty-four otherwise healthy men with suspected high-grade varicocele, comprised of 28 patients with grade 2 and 96 with grade 3 varicocele, were referred to us by their primary care providers to determine their exact grade so that they could be exempted from the compulsory armed force service if they had grade 3 varicocele. In the grade 2 and grade 3 groups, mean sperm concentration and mean sperm motility were 80.89 million per milliliter (SD, 38.98 million/mL; median, 74.5 million/mL; range, 22-210 million/mL) and 78.77 million per milliliter (SD, 41.34 million/mL; median, 77 million/mL; range, 0-223 million/mL) and 58.39% (SD, 13.7%; median, 60%; range, 22-75%) and 60.31% (SD, 16.93%; median 65%; range, 0-80%), respectively, with no statistically significant differences between the two groups, no patient with infertility as a complaint during a 20-month period, and no patient with sperm concentrations of <20 million/mL, but with six patients with sperm motilities <50%. In summary, by far the great majority of patients with high grade varicocele have more than normal sperm output. Higher grades of varicocele are not associated with more pronounced deleterious effects on sperm concentration and percentage motility. Incidentally diagnosed high-grade varicocele is not a progressive condition, and almost all patients retain normal semen quality, at least over a period of 20 months.

Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis

OBJECTIVE

To determine the efficacy of varicocelectomy as a treatment for male factor infertility by improving the chance of spontaneous pregnancy.

DESIGN

Meta-analysis.

SETTING

Cleveland Clinic's Glickman Urological Institute.

PATIENT(S)

Infertile men with abnormal results on semen analyses and a palpable varicocele.

INTERVENTION(S)

Surgical varicocelectomy.

MAIN OUTCOME MEASURE(S)

Spontaneous pregnancy outcome.

RESULT(S)

The odds of spontaneous pregnancy after surgical varicocelectomy, compared with no or medical treatment for palpable varicocele, were 2.87 (95% confidence interval [CI], 1.33-6.20) with use of a random-effects model or 2.63 (95% CI, 1.60-4.33) with use of a fixed-effects model. The number needed to treat was 5.7 (95% CI, 4.4-9.5).

CONCLUSION(S)

Surgical varicocelectomy in infertile men with palpable lesions and at least one abnormal semen parameter improves the odds of spontaneous pregnancy in their female partners. Five studies were included (two randomized, three observational). All were scored for bias. Our study suggests that varicocelectomy in selected patients does indeed have beneficial effects on fertility status.

Treatment of bleeding varicose veins of the scrotum with percutaneous coil embolization of the left spermatic vein: a case report

Percutaneous coil embolization of the spermatic vein offers a minimally invasive method for treating symptomatic varicose veins of the scrotum. We describe the case of a 63-year-old man with multiple comorbidities and persistent bleeding from scrotal varicosities. Venography revealed significant left spermatic vein reflux and a large left varicocele. Percutaneous coil embolization of the left spermatic vein completely resolved the bleeding from the left side of the patient's scrotum. Although many vascular specialists possess the technical skills to perform this procedure, they may not be familiar with its use in the treatment of scrotal varicosities and varicoceles.

Right varicocele and hypoxia, crucial factors in male infertility: fluid mechanics analysis of the impaired testicular drainage system

Varicocele is considered a predominantly unilateral left-sided disease. However, since male fertility is preserved with only one healthy testis, infertility perforce represents bilateral testicular dysfunction. It was hypothesized that: (i) right varicocele cannot be diagnosed by palpation and therefore has not been treated in the past by the traditional treatment, and (ii) right varicocele causes impaired oxygen supply in the right testicular microcirculation, leading to germ cell degeneration. This study performed venographies of both right and left internal spermatic veins during the treatment of 840 infertile men with varicocele and analysed the results using tools of fluid mechanics. Histopathology of the right testis revealed stagnation of blood flow and degenerative changes attributed to lack of adequate oxygenation in all testicular cell types. Right varicocele was found in the vast majority of the patients. We found that due to the destruction of one-way valves, pathologic hydrostatic pressure is produced in the testicular venous microcirculatory system about five times higher than normal, exceeding arteriolar pressure. The pressure gradient between the arterioles and venules in the testicular tissue is therefore reversed, leading to persistent hypoxia. Right varicocele, although undetected, is prevalent in infertile men with varicocele, hence only bilateral occlusion of the internal spermatic veins, including the associated bypasses, eliminating the pathologic hydrostatic pressure will lead to resumption of arterial blood flow in the testicular microcirculation.

Rational diagnosis and treatment in infertility

Subfertility is a statistical concept. When a pregnancy has not been achieved within a year of unprotected intercourse, the odds are that an underlying pathological mechanism is at play. Advanced female age, longer duration and primary infertility, are important prognostic factors, suggestive of low fecundity and indicating a need for further diagnosis and treatment. Many diagnostic tests only have screening value and the only gold standards are hysteroscopy and laparoscopy. Severely impaired semen quality should lead to andrological work-up. Postcoital test and endometrial biopsy are obsolete. Treatment should preferably be aetiological, such as in anovulation, and sometimes also in endometriosis and tubal infertility. Primary treatment of male infertility is not proven to be advantageous. Conception-enhancing techniques such as intrauterine insemination (IUI), in vitro fertilisation (IVF) with or without intracytoplasmic sperm injection (ICSI), have shown to be effective. As a rule, and where possible, IUI is preferred and only if four to six cycles have failed should IVF be offered.

Treatment of varicocele in subfertile men: The Cochrane Review--a contrary opinion

OBJECTIVE

A recent Cochrane meta-analysis of randomised clinical trials (RCTs) concluded that surgical or radiological treatment of varicocele in men from couples with otherwise unexplained subfertility cannot be recommended. The aim of the present study is to address criticisms of this review carrying out a critical analysis of all available RCTs.

MATERIALS AND METHODS

The eight randomised clinical trials selected in the last Cochrane Library systematic review have been evaluated. All RCTs including patients either with normal semen analysis or subclinical varicocele have been excluded. Inclusion criteria, number and clinical characteristics of randomised patients, and outcomes reported in terms of pregnancy rate one year after randomisation have been described in the remaining studies.

RESULTS

Only 3/8 RCTs included patients with abnormal semen analysis and palpable varicocele. Overall 120 patients in the treatment group and 117 in the control group were randomised. The studies turned out to be heterogeneous in terms of inclusion criteria and clinical characteristics of the analysed patients. Their methodological quality and statistical power have to be considered poor. Moreover, the "as treated" cumulative analysis showed a significant increase in pregnancy rate in patients who underwent varicocele treatment (36.4%) compared with the control group (20%) (p = 0.009).

CONCLUSIONS

The RCTs included in the last Cochrane review concerning the efficacy of varicocele treatment in subfertile couples were heterogeneous and methodologically poor. The pooling of these studies cannot result in a good quality meta-analysis. The Cochrane meta-analysis conclusions should not support guidelines recommendation against varicocele treatment in subfertile patients. Data from ongoing studies should provide more information in this topic.