Sao Paulo Med J. 2013;131(1):67 67
Surgery or embolization for
varicoceles in subfertile men
Anja C. J. Kroese, Natascha M. de Lange, John Collins,
Johannes L. H. Evers
The independent commentary was written by Geraldo de
BACKGROUND: A varicocele is a meshwork of distended blood ves-
sels in the scrotum, usually left-sided, due to dilatation of the spermatic
vein. Although the concept that a varicocele causes male subfertil-
ity has been around for more than 50 years now, the mechanisms by
which a varicocele would affect fertility have not yet been satisfactorily
explained. Neither is there sufficient evidence to explain the mecha-
nisms by which varicocelectomy would restore fertility. Furthermore, it
has been questioned whether a causal relation exists at all between the
distension of the pampiniform plexus (a network of many small veins
found in the human male spermatic cord) and impairment of fertility.
OBJECTIVES: To evaluate the effect of varicocele treatment on live birth
and pregnancy rate in subfertile couples where the male has a varicocele.
Search: We searched the Cochrane Menstrual Disorders and Subfertility
Group Trials Register (12 September 2003 to January 2012), the Cochrane
Central Register of Controlled Trials (CENTRAL) in The Cochrane Library
Issue 1, 2012), Medline (January 1966 to January 2012), Embase (January
1985 to January 2012), PsycINFO (to Week 1 2012) and reference lists of
articles. In addition, we handsearched specialist journals in the field from
their first issue until 2012. We also checked cross-references, references
from review articles and contacted researchers in the field.
Selection criteria: Randomized controlled trials (RCTs) were included
if they were relevant to the clinical question posed. If they reported
pregnancy rates or live birth rates as an outcome measure, and if they
reported data in treated (surgical ligation or radiological emboliza-
tion of the internal spermatic vein) compared to untreated or placebo
groups. Two authors independently screened potentially relevant tri-
als. Any differences of opinion were resolved by consensus (none oc-
curred for this review).
Data collection and analysis: Ten studies met the inclusion criteria for the
review. For one study we had only data from a published abstract. All
ten studies only included men from couples with subfertility problems;
one excluded men with sperm counts less than 5 million per mL and
one excluded men with sperm counts less than 2 million per mL, with or
without progressive motility of less than 10%. Two trials involving clinical
varicoceles included some men with normal semen analysis. Three studies
specifically addressed only men with subclinical varicoceles. Studies were
excluded from meta-analysis if they made comparisons other than those
MAIN RESULTS: The meta-analysis included 894 men. No studies re-
ported live birth. The combined fixed-effect odds ratio (OR) of the 10
studies for the outcome of pregnancy was 1.47 (95% confidence interval
(CI) 1.05 to 2.05, very low quality evidence), favouring the intervention.
The number needed to treat for an additional beneficial outcome was
17, suggesting benefit of varicocele treatment over expectant manage-
ment for pregnancy rate in subfertile couples in whom varicocele in the
man was the only abnormal finding. Omission of the studies including
men with normal semen analysis and subclinical varicocele, some of
which had semen analysis improvement as the primary outcome rather
than live birth or pregnancy rate, was the subject of a planned sub-
group analysis. The outcome of the subgroup analysis (five studies) also
favoured treatment, with a combined OR 2.39 (95% CI 1.56 to 3.66). The
number needed to treat for an additional beneficial outcome was 7. The
evidence was suggestive rather than conclusive, as the main analysis
was subject to fairly high statistical heterogeneity (I2 = 67%) and find-
ings were no longer significant when a random-effects model was used
or when analysis was restricted to higher quality studies.
AUTHORS’ CONCLUSIONS: There is evidence suggesting that treat-
ment of a varicocele in men from couples with otherwise unexplained
subfertility may improve a couple’s chance of pregnancy. However, find-
ings are inconclusive as the quality of the available evidence is very low
and more research is needed with live birth or pregnancy rate as the
This is the abstract of a Cochrane Review published in the
Cochrane Database of Systematic Reviews (CDSR) 2012, issue 10,
DOI: 10.1002/14651858.CD000479.pub1 (http://onlinelibrary.wiley.
com/doi/10.1002/14651858.CD000479.pub5/abstract). For full citation
and authors details see reference 1.
The full text is freely available for Latin America and the Caribbean
1. Kroese AC, de Lange NM, Collins J, Evers JL. Surgery or embolization
for varicoceles in subfertile men. Cochrane Database Syst Rev.
Varicocele is a state of dilatation of the spermatic veins (pampiniform
plexus) of the testicles. Clinical varicocele (visible and palpable) has a
surgical indication only when the condition causes pain or there is an
The discovery that surgery for varicocele can improve semen qual-
ity (1988), with consequent improvement of fertility among men
with this malformation, was a major step forward in treatments for
male infertility.1 The incidence of left varicocele in subfertile men
is around 40%. There is no longer any doubt that varicocele affects
semen quality, giving rise to low sperm counts and low motility. Al-
though the reasons for these deleterious effects are not clear, it is
now accepted that surgery to correct varicocele should be indicated
for subfertile men.
We prefer an incisional access, which may improve semen quality in
66% of the cases, leading to a pregnancy rate of 35%.2
Geraldo de Campos Freire. Full Professor and Associate Professor of
Urology, Faculdade de Medicina da Universidade de São Paulo (FMUSP),
São Paulo, Brazil.
1. Dubin L, Amelar RD. Varicocelectomy: twenty-five years of experience.
Int J Fertil. 1988;33(4):226-8, 231-5.
2. Turek PJ. Infertilidade masculina. In: Tanagho EA, McAninch JW,
editores. Urologia geral de Smith. Porto Alegre: AMGH Editora Ltda;
2010. p. 684-716.