Insemination data on men with varicoceles**Presented at the 47th Annual Meeting of The American Fertility Society, Orlando, Florida, October 21 to 23, 1991

The benefits of varicocele repair for achieving pregnancy in male infertility: A systematic review and meta-analysis

Introduction

Varicocele is one of the most common treatable causes of male infertility. However, the decision to perform varicocelectomy before starting a fertility program remains controversial. This study aimed to thoroughly review and analyze the benefit of varicocele repair and its impact on the success rate of a fertility program.

Materials and methods

A systematic literature search was performed using MEDLINE, Cochrane Library, and Wiley Library. The primary outcome was the pregnancy rate, and the secondary outcomes were live birth rate and surgical sperm retrieval success rate. Outcomes were compared between men who underwent treatment for a varicocele and those that did not. The pooled analysis data are presented as odds ratios with 95% confidence intervals.

Results

A total of 31 articles were included in the meta-analysis. The pregnancy rate was significantly higher in the treated group (odds ratio = 1.82; 95% confidence interval: 1.37-2.41; P < 0.0001) along with the live birth rate (odds ratio = 2.80; 95% confidence interval: 1.67-4.72; P = 0.0001). The further subgroup analysis revealed a higher pregnancy rate in treated men with azoospermia, subnormal semen parameters, and normozoospermia (P = 0.04, P = 0.0005, and P = 0.002, respectively), while the live birth rate was only significantly higher in the treated men with subnormal semen parameters and normozoospermia (P = 0.001 and P < 0.0001). Treated varicocele also led to a higher sperm retrieval rate in azoospermic patients (odds ratio = 1.69; 95% confidence interval: 1.16-2.45; P = 0.006).

Conclusions

Varicocele repair increased the pregnancy and live birth rates regardless the semen analysis result, along with the sperm retrieval success rate in azoospermic men. Thus, varicocele repair may be beneficial prior to joining a fertility program.

A review of varicocele treatment and fertility outcomes

Varicoceles are reported to be present in a significant proportion of men presenting with subfertility and are more common amongst this group than in the general population. Opinion still remains divided amongst clinicians managing male factor infertility as to whether varicoceles alter the probability of spontaneous conception and/or pregnancy and live birth rates after fertility treatment. The debate as to whether varicoceles should be treated or not has intensified in recent years. This is due to the concerns regarding the impact of varicoceles on not only conventional semen parameters, but also the potential effects that they may have at the cellular level (an increase in circulating reactive oxygen species (ROS) resulting in sperm DNA fragmentation, even when conventional semen parameters are within the normal reference ranges). It has been suggested that treating the varicocele may result in improvements in the semen parameters, the fertilization and pregnancy rates for both spontaneous pregnancy as well as following in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment. ICSI can still be used for Assisted Reproduction Treatment (ART) in the presence of suboptimal semen parameters. However, it is an invasive and expensive technique with potential adverse effects on the offspring. As far as we are aware, there are no randomized controlled trials comparing the clinical/cost effectiveness of varicocele treatment versus the immediate use of ICSI on pregnancy rates. Previous modelling exercises are old and do not take into consideration current practices and trends such as rising female age and time to pregnancy. The conflicting advice that patients sometimes receive, challenges our commitment to evidence-based practice. The only way to resolve the controversy is to undertake an appropriately powered randomized trial, assessing clinical- and cost-effectiveness and the time to pregnancy following varicocele treatment and comparing this to a no treatment group.

Varicocele Repair Prior to Assisted Reproductive Technology: Patient Selection and Special Considerations

Clinical varicoceles are one of the most commonly identified physical exam abnormalities in men presenting with infertility. Clinical varicoceles can cause impaired spermatogenesis and surgical correction can improve semen parameters in select men. Increasingly, andrologists are performing varicocele repairs prior to intrauterine insemination (IUI), in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI) to boost male fertility potential. In this review, we evaluated the available literature 1) to determine if varicocelectomy prior to IUI or assisted reproductive technologies proved to improve sperm production or pregnancy outcomes; and 2) to identify who may be the ideal candidate for pre-IUI/ART varicocelectomy. Overall, few studies have explored this topic and little can be concluded about the impact of varicocelectomy prior to IUI. The evidence, however, does support that correcting a clinical varicocele can increase pregnancy outcomes in couples who plan to pursue IVF or ICSI. When selecting patients for varicocelectomy prior to IUI or ART, clinicians should evaluate female age as improvement in semen parameters can take 6 months after varicocelectomy and this duration of time may be deleterious in cases of advanced maternal age when each cycle becomes increasingly important. Overall, the currently limited literature regarding clinical varicoceles correction demonstrates that pregnancy rates can be increased when comparing patients who have undergone varicocelectomy prior to ART with those who had clinical varicocele but did not undergo surgery.

Indications and outcomes of varicocele repair

Varicoceles exert deleterious effect on testicular function. The condition has been associated with male infertility, testicular hypotrophy and pain. These comprises the common indications for varicocele repair currently. Significant improvement in semen parameters and pregnancy outcomes had been suggested by reports decades ago. However, selection of the best candidates remains an issue since not all patients respond positively to treatment. Consensus has been reached in recent decade after the publication of a series of meta-analyses. Significant improvement in pregnancy outcomes were reported in patients with clinical varicocele and abnormal semen parameters. Varicocelectomy in adolescents with testicular hypotrophy was supported by the positive implication on catch-up growth and semen parameters. However, little is known about the treatment effect of adolescence varicocelectomy on long term fertility and paternity rate. Recent studies on outcome of varicocele repair for pain consistently demonstrated a resolution rate of approximately 90% and support varicocele-associated pain as an indication for surgery. Alternate indications for varicocele repair have been proposed in recent decade. Despite the encouraging preliminary data, most studies were uncontrolled retrospective series. Although varicocelectomy may not obviate the need for assisted reproductive techniques in patients with non-obstructive azoospermia, it potentially increases sperm retrieval rate. The significant increase in serum testosterone after varicocelectomy in patients with androgen deficiency may open an alternative treatment for hypogonadism. The adjunctive role of varicocelectomy before assisted reproduction and the significant decrease in sperm DNA fragmentation after varicocele repair deserve further well-designed controlled studies.

The great debate: varicocele treatment and impact on fertility

OBJECTIVE

To evaluate the current literature on the impact and potential mechanisms of varicocele repair on male fertility.

DESIGN

Pertinent articles were identified through computer PubMed search on varicocele repair and male factor infertility. References of selected articles were hand searched for additional citations.

CONCLUSION(S)

Varicocele repair has been shown to reverse a spectrum of effects contributing to men with impaired fertility. Clinical studies on the intervention have illustrated variable effects on postoperative sperm parameters and pregnancy rates (PR). Studies with conflicting results suffer from a significant number of confounding variables such as variable repair technique or lack of controls. Additional studies are warranted on the role of modern microsurgical varicocelectomy given the improvements in assisted reproductive technologies (ART).

Economics of treatments for male infertility

Economic factors play a major role in the consideration of treatment options for male reproduction. This article has summarized the data and provided new insight into how patients, insurers, and populations evaluate competing therapies for male infertility. Many studies are difficult to interpret because of differing success rates and monetary bias. Future studies comparing line-by-line costs and reimbursements by independent sources may be the best way to evaluate different treatments.

A modified acrosome induction test

Many types of acrosome induction tests require special equipment and reagents that are not available to most clinicians; thus, simpler tests seem desirable. A modified acrosome induction test has been developed that uses basic reagents and a light microscope, which are available in most office settings. A hypoosmotic swelling test and a double stain (Bismark brown and rose Bengal) were combined to evaluate the viable acrosome reaction (AR) among 74 infertile men and 42 control men. The study included 34 infertile males without varicoceles, 20 with nonrepaired varicoceles and 20 with repaired varicoceles. On each test day, a specimen from a fertile donor was run as a control. The spontaneous acrosome reaction was recorded in semen before and after capacitation. The final % viable acrosome reaction equaled the capacitated value minus the spontaneous value for whole semen. The mean % viable AR among the control specimens was 16% with no values less than 10%. This mean value for controls was significantly greater than the mean % viable AR in each patient group. There were no overlaps in the 95% confidence intervals. When the study group was stratified according to normal acrosome induction tests or >10% viable AR, 30 patients had a normal test and 44 had abnormal tests. Six patients with varicoceles and an abnormal acrosome induction test had a varicocelectomy, and 2 (33%) converted their acrosome induction test to normal after at least 6 months of follow-up. Nine patients had in vitro fertilization (IVF), 3 had a poor result, and all had an abnormal acrosome induction test. Six had a good result with IVF and all 6 had a normal acrosome induction test. Thus, the acrosome induction test described in this report may be performed in any office laboratory to detect subtle male factor problems. The results may be helpful for planning IVF, intracytoplasmic sperm injection, or varicocele surgery for infertile men.