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Male Infertility
Varicocele Treatment in Light of controlled trials and observational studies. Although these data are
Evidence-based Medicine not yet published, we concluded from our meta-analysis that surgical
In this age of evidence-based medicine, it is interesting that few varicocelectomy is an effective treatment for improving semen
randomised controlled studies have been performed to clarify the cost- parameters of infertile males with clinically palpable varicocele. Based
effective benefit of varicocelectomy. Reviews concerning efficacy of
varicocelectomy in subfertile couples are heterogeneous and include
studies with suboptimal methodology.
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Comparison among these
Identifying those individuals with
reported trials is confounded by substantial differences in important
factors such as varicocele size, cause of infertility, seminal parameter varicocele who will present better
criteria for study inclusion, concurrent female fertility factors and short
benefit from varicocele treatment is
follow-up time after varicocelectomy.
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always a challenge for andrologists.
The results of a systematic review by Evers and Collins in 2003 had a
negative influence on the varicocele treatment recommendations of
the EUA Working Group on Male Infertility.
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Only randomised, on the data from current literature and contrary to previous meta-
controlled trials were included that addressed varicocele repair for analyses, our study suggests that varicocelectomy does indeed have a
male subfertility, and the conclusion was that surgery or radiological beneficial effect on fertility status by improving the odds of
treatment of varicocele does not seem to be an effective treatment for spontaneous pregnancy in female partners.
male or unexplained subfertility.
Our results further support that the improvement in semen parameters
A recent review challenged the meta-analysis by Evers and Collins, achieved with varicocelectomy may help infertile couples achieve
carrying out their own critical analysis of all available randomised, clinical pregnancy spontaneously or with less invasive and inexpensive
trials.
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As the AUA and ASRM did not recommend varicocele repair in techniques, such as IUI.
patients with normal semen analyses or subclinical varicoceles, five out of
eight studies selected in the previous meta-analysis were excluded to Conclusion
allow a critical assessment of current treatment guidelines.
34,35,84–86
Based Varicocele remains a common finding in infertile men and is often the
on this review, Ficarra et al. concluded that the meta-analysis by Evans sole identifiable cause of infertility in couples. There is convincing
and Collins would support varicocele treatment in the context of only evidence that varicoceles produce a progressive harmful effect upon
examining studies in the literature that were consistent with current the testis, resulting in the decline of seminal parameters. Figure 1
guideline recommendations. It suggested supporting continuing summarises the most common indications and the expected benefits
varicocele treatment for improvement of fertility instead.
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from the varicocele repair.
The two most important randomised, controlled studies reported an The main goal of varicocelectomy is to preserve testicular function and
improvement in seminal parameters following varicocele repair, but initiate pregnancy in infertile couples. However, even when pregnancy
they are discordant regarding pregnancy outcomes and maintain the is not achieved, improved seminal quality after surgery can obviate or
downstage the need for assisted reproductive techniques. Identifying
Contrary to previous meta-analyses, those individuals with varicocele who will receive better benefit from
varicocele treatment is always a challenge for andrologists.
our study suggests that
varicocelectomy does indeed have a Current data support the assertion that varicocelectomy is successful in
beneficial effect on fertility status by
reversing the harmful effects of varicocele on testicular function
in selected patients by improving seminal parameters in the majority of
improving the odds of spontaneous
controlled studies. While the topic of varicocele treatment regarding
pregnancy in female partners.
pregnancy will remain controversial due to the limited number of
randomised, controlled clinical trials, the new meta-analysis supports
controversy concerning the effects of varicocele treatment upon improvements in pregnancy rates with varicocele ligation. Although ART
fertility.
87,88
Recently, our centre tried to resolve this controversy by can achieve rapid results, considering the higher expenses involved and
conducting a meta-analysis that examined the effects of potential safety issues – as well as the fear of transferring the unnecessary
varicocelectomy on semen parameters and pregnancy rates for burden of invasive treatment onto healthy female partners – current
infertile couples in which the male partner had abnormal semen literature indicates that evaluating and treating the specific male
parameters and clinical varicocele. We analysed both randomised, infertility cause is more cost-beneficial for infertile couples. ■
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