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Male Infertility
Varicocele – A Dilemma for the Urologist
Current Concepts
a report by
Marcello Cocuzza, Edmund S Sabanegh, Jr and Ashok Agarwal
Reproductive Research Center, Glickman Urological Institute, Cleveland Clinic
Although varicocele repair is widely used as a treatment for male infertility might be treated with assisted reproductive techniques
infertility, the effectiveness of varicocelectomy has been a focus of instead of specific therapy.
intense debate for nearly 50 years. A number of conflicting reports in
the literature has resulted in divergent guidelines by various The following review discusses current concepts in varicoceles and
professional groups. The American Urological Association (AUA) and summarises the leading theories on the mechanisms for varicocele-induced
the American Society for Reproductive Medicine (ASRM) recommend testicular damage. It reviews existing literature on the efficacy
treatment for clinical varicoceles when a male partner has abnormal of varicocelectomy for the treatment of infertility. It discusses the
semen parameters. The National Collaborating Center for Women’s role of varicocelectomy in the management of varicoceles in the adolescent
Health of 2005 suggests not offering surgery for men with varicocele as well as in non-obstructive azoospermic patients. Finally, the authors
as a fertility treatment, while the European Association of Urology critically review the cost-effectiveness of the surgical treatment of a
(EUA) still considers it controversial. varicocele compared with assisted reproductive techniques.
There is significant evidence in the literature to support the theory Varicocele and Male Infertility
that varicocele has a harmful effect on the testes and that Over the past decade, the association of varicocele with male
varicocelectomy can prevent the progressive decline in testicular subfertility has been repeatedly demonstrated and the beneficial effect
function, as well as reverse the damage. However, there are few of varicocele repair in infertile men with oligoasthenospermia has been
adequately controlled prospective trials concerning the effect of reported.
1
Varicocele is implicated as a factor in 35–50% of men with
varicocele repair on fertility. primary infertility and in up to 81% of men with secondary infertility.
2,3
The higher incidence in secondary infertility implicates varicoceles in
The development of intracytoplasmatic sperm injection (ICSI) as an producing a progressive decline in testicular function over time.
effective therapy for cases of male infertility has become a valid means
of overcoming multiple sperm deficiencies. ICSI has been suggested by An association of abnormal semen parameters in infertile patients with
some to represent the solution for all cases of male factor infertility, the presence of varicocele during physical examination has been
regardless of aetiology. Even men with potentially treatable causes of reported by several studies. In 1965, MacLeod first reported that the
majority of semen samples obtained from 200 infertile men with
varicocele had decreased sperm count, decreased motility and
Marcello Cocuzza is a Fellow in Andrology in the Glickman
Urological Institute at the Cleveland Clinic. Since 2004, he has
increased abnormal forms.
4
A study conducted by the World Health
been a staff member in the Urology Department of Hospital
Organization (WHO) on varicocele found its presence in 25.4% of
das Clinicas, Sao Paulo, Brazil. His research interests are in the
infertile men with abnormal semen, noting that it is accompanied by
surgical treatment of male infertility and in unravelling the role
of oxidants in sperm dysfunction.
decreased testicular volume, lower total sperm count and a decline in
Leydig cell secretion.
5
Large numbers of uncontrolled studies have suggested that varicocele
Edmund S Sabanegh, Jr is Chief of the Section of Male
Infertility for the Glickman Urological Institute. His research
ligation can improve sperm count, motility and morphology. Overall,
interests include complex reconstructions for obstruction of
varicocelectomy studies reported significant improvements in one
the reproductive tract, testicular blood flow, varicoceles and
or more semen parameters in 65% of men, and pregnancy rates of
environmental influences on fertility. He heads one of the
few male infertility fellowship programmes in the US, which
40% in couples.
6
However, the effectiveness of varicocele repair in
combines basic research with extensive clinical experience.
terms of pregnancy rate improvement is a controversial matter in the
literature due to the large number of poorly designed and
uncontrolled studies.
Ashok Agarwal is Director of the Reproductive Research
Center and Director of the Clinical Andrology Laboratory and
Reproductive Tissue Bank at the Cleveland Clinic’s Glickman
Various mechanisms have been proposed for infertility in men with
Urological and Kidney Institute. Professor Agarwal is
varicocele. The aetiology remains to be proved, but suggested
recognised internationally for his innovative research into the
pathophysiology of male infertility. mechanisms include hypoxia and stasis, testicular venous
hypertension, elevated testicular temperature, increase in spermatic
E: agarwaa@ccf.org
vein catecholamine and increased oxidative stress.
7–12
However, the
exact cause is still unknown.
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