Agarwal.qxp 25/2/08 12:42 pm Page 56
Table 1: Pre-operative Predictors of Seminal Improvement
Although assisted reproduction technology (ART) provides an
opportunity to families with infertility, the potential medical risks entailed
by multiple-gestation pregnancies and the associated costs cannot go
High-grade varicocele (grade III)
unnoticed. Therefore, couples considering assisted reproductive
Lack of testicular atrophy
techniques should be aware of the risks of these procedures. Medical
Normal serum FSH
Total motility >60%
risks include ovarian hyperstimulation and multiple gestations.
Total motile sperm count >5x10
Positive GnRH stimulation test In addition to the safety concerns, which procedure is more cost-
FSH = follicle-stimulating hormone; GnRH = gonadotropin-releasing hormone. effective for infertile couples with male varicocele in this era of cost-
containment awareness: ICSI or varicocele repair? Schlegel first
fertility after varicocelectomy.
Varicocele repair is more likely to reported a comparison of ICSI and varicocele repair using a ‘cost per
improve fertility in patients with serum FSH concentrations lower than delivery’ analysis and concluded that primary treatment with
11.7mIU/ml or lower than 300ng/ml.
varicocelectomy was more cost-effective than sperm retrieval/ICSI,
while providing comparable delivery rates.
Total hospital delivery
The gonadotropin response to exogenous gonadotropin-releasing
hormone (GnRH) test has been suggested by some as a means to identify
Although assisted reproduction
patients who would benefit from varicocele ligation. Atikeler et al. showed
technology provides an opportunity to
that a significant elevation in FSH (approximately 1.5–2.0 times baseline)
and luteinising hormone (LH) (approximately 2.0–2.5 times baseline) 30–60 families with infertility, the potential
minutes after an intranasal bolus of GnRH (100mg) was a predictor in
medical risks entailed by multiple-
identifying patients whose semen parameters would improve after
Similarly, Segenreich et al. reported that 81% of men
gestation pregnancies and the
with an exaggerated GnRH test response had a post-operative
associated costs cannot go unnoticed.
improvement in their sperm variables, whereas only 19% of men lacking
an exaggerated response showed improvement. Corresponding pregnancy costs, as well as costs attributable to multiple gestations and
rates at 18 months in the two groups were 67.4 and 9.3%, respectively. complications, were analysed. The average US reported delivery rate
The authors concluded that a positive pre-operative GnRH test is a good after one attempt of ICSI was 28% compared with 30% found after
predictor of improvement in semen parameters and pregnancy after varicocele repair. The average cost per delivery for varicocelectomy
was US$26,268, whereas for ICSI it was estimated at US$89,091.
Y chromosome microdeletions are another factor that portends little or no Recently, Meng et al. applied a decision-analysis model to compare the
improvement after varicocele ligation. The Y chromosome plays a critical cost of pregnancy for varicocelectomy versus ART treatment in
role in the control of spermatogenesis. Y chromosome microdeletions can varicocele patients.
Decision models are constructed with pre-
be detected in as many as 4–14.3% of oligospermic men and in up to 18% defined assumptions and are used to estimate outcomes once several
of azoospermic men.
Moro et al. reported that Y chromosome options for treatment are available. The authors concluded that initial
deletions were observed in seven out of 40 infertile patients (17.5%) varicocele repair was more cost-effective than ART treatment for
presenting with severe oligospermia (fewer than 5x10
sperm/ml), bilateral infertile couples.
testicular volume loss and varicocele. Interestingly, no deletions were found
in 80 patients with varicocele and mild oligozoospermia (sperm count After varicocele repair, a couple can proceed with assisted
Pryor et al. examined the incidence of Y chromosome reproduction if pregnancy is not achieved. Varicocele repair may allow
microdeletion in 200 consecutive infertile men and found that 3% of those some couples to proceed with IUI prior to proceeding with more
with varicocele had microdeletions.
Cayan et al. reported results after advanced assisted reproductive techniques, since studies suggest that
varicocelectomy in five patients who had co-existing Y chromosome varicocelectomy improves the effectiveness of subsequent IUI.
deletions and found no significant improvement in seminal parameters or While ICSI provides a viable alternative for the treatment of infertile
These findings suggest that men with poor seminal couples with varicocele, current evidence supports that the treatment
parameters and Y chromosome microdeletions might have an incidental of varicocele is a more cost-effective therapy for infertility.
varicocele for which surgical repair is unlikely to improve fertility.
Managing Varicocele in Adolescents
These prognostic indicators can facilitate the identification of patients with Although varicocele is cited as one of the leading causes of male
a better prognosis for varicocele repair, or the choice of those couples infertility, it is essential to recognise that varicocele does not typically
more likely to be initial candidates for assisted reproductive techniques. begin in adulthood, but rather in the peri-pubertal period.
Epidemiological studies reveal that varicocele is not generally present
Varicocelectomy or Assisted Reproductive Technology – in children under 10 years of age, and its incidence gradually increases
Which Is Better? at the beginning of the second life decade.
The incidence of
In the era of intracytoplasmic sperm injection, the role of andrologists varicocele in adolescents is approximately 15% by the late teenage
has been transformed. The relative pregnancy rates achieved by this years, a rate similar to the general population, and with the same
modality have led to a troubling decrease in efforts to establish a distribution of grades. Varicocele incidence peaks at the age of 15
correct diagnosis of infertility cause. years and remains relatively stable thereafter.
56 EUROPEAN GENITO-URINARY DISEASE 2007