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DR. SCHIFF is Assistant Clinical Professor, Urology, Mount Sinai School of Medicine, New York, NY.
DR. CHAN is Director of Male Reproductive Medicine, Department of Urology, Department of Obstetrics & Gynecology, McGill University Health Centre, Montreal, Canada.
Dr. Chan argues that repairing all clinically significant varicoceles can at least enhance semen parameters-and at best might enhance fertility. Dr. Schiff, on the other hand, says repair only those of men to benefit the most.
Yes. Repairing clinically significant abnormalities can enhance testicular function and might improve fertility.
Various theories have been proposed for the pathophysiology of varicoceles in male infertility. Most investigators believe that venous reflux and testicular temperature elevation both play important roles in varicocele-induced testicular dysfunction. Keep in mind that varicoceles can co-exist with other infertility conditions; hence fertility evaluation and management shouldn't end after the initial diagnosis of a varicocele, particularly when a severe impairment in the semen profile is associated with only a low-grade varicocele.
1. enhancement of the endocrinologic function of the testis by elevating serum testosterone;
2. enhancement of sperm quantity in semen;
3. enhancement of sperm quality in terms of motility and morphology;
4. enhancement of spermatogenesis, even in cases of nonobstructive azoospermia, to the point where 30% to 50% of patients may have sperm returning to the ejaculate after varicocele repair, obviating sperm retrieval by surgery for assisted reproduction;
5. enhancement of the natural pregnancy rate; and
6. enhancement of sperm DNA quality and other physiologic aspects of sperm function.
As a result, most literature on varicocele repair has taken the form of case series and uncontrolled studies. However, several well-designed RCTs evaluating the benefit of repairing clinically significant varicoceles are also available. The oft-quoted study by Madgar and colleagues showed a pregnancy rate of 60% in the varicocele treatment group after 12 months, compared with only a 10% pregnancy rate in the untreated controls.2 Subsequently, after the controls had undergone delayed varicocele treatment, pregnancy rates rose to 44%.
Even with meta-analysis, due to the limited number of RCTs on the benefit of varicocelectomy, it's difficult to draw proper conclusions given the heterogeneity of the inclusion criteria and clinical characteristics of the analyzed patients.3 In one meta-analysis aimed at evaluating the benefit of varicocele repair, the authors managed to include only seven randomized controlled studies.4 Of particular interest is that in four out of the seven studies, a significant number of patients presented with subclinical varicoceles. Furthermore, even patients with normal semen analyses were included in some of the studies analyzed. As such, the authors failed to detect a significant clinical benefit in the treatment of these patients. Their report unfortunately led many readers to incorrectly generalize that varicocele repair is usually futile.