Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair.

Department of Surgery, Umm Al-Qura University, Makkah, Saudi Arabia.
European Urology (Impact Factor: 10.48). 07/2011; 60(4):796-808. DOI: 10.1016/j.eururo.2011.06.018
Source: PubMed

ABSTRACT Varicocele is a common condition, found in many men who present for infertility evaluation.
To assess the effect of varicocelectomy on male infertility.
A literature search was performed using Embase and Medline. Literature reviewed included meta-analyses and randomized and nonrandomized prospective (controlled and noncontrolled) studies. In addition, a new meta-analysis was performed.
Four randomized controlled trials reporting on pregnancy outcome after repair of clinical varicoceles in oligozoospermic men were identified. Using the random effect model, the combined odds ratio was 2.23 (95% confidence interval [CI], 0.86-5.78; p=0.091), indicating that varicocelectomy is moderately superior to observation, but the effect is not statistically significant. We identified 22, 17, and 5 prospective studies reporting on sperm concentration, total motility, and progressive motility, respectively, before and after repair of clinical varicocele. The random effect model combined improvement in sperm concentration was 12.32 million sperm per milliliter (95% CI, 9.45-15.19; p<0.0001). The random effect model combined improvement in sperm total and progressive motility were 10.86% (95% CI, 7.07-14.65; p<0.0001) and 9.69% (95% CI, 4.86-14.52; p=0.003), respectively. These results indicate that varicocelectomy is associated with a significant increase in sperm concentration as well as total and progressive motility. Prospective studies also show that varicocelectomy reduces seminal oxidative stress and sperm DNA damage as well as improving sperm ultramorphology. Studies indicate that a microsurgical approach to a varicocele repair results in less recurrence and fewer complications than other techniques.
Although there is no conclusive evidence that a varicocele repair improves spontaneous pregnancy rates, varicocelectomy improves sperm parameters (count and total and progressive motility), reduces sperm DNA damage and seminal oxidative stress, and improves sperm ultramorphology. The various methods of repair are all viable options, but microsurgical repair seems to be associated with better outcomes.

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    ABSTRACT: We reviewed a large number of patients from 2000 to 2010 that underwent varicocoele correction using the retrograde sclerotization approach. Three hundred and seventy-six of them were included in the study, as they met the inclusion criteria. Mean age at the time of surgery was 32 years (SD: 6.5); 32% of them were 35 years and older. Patients were classified according to the clinical classification (GC) and Sarteschi's Doppler ultrasound classification (GS). The patients showed up at the clinic after an average time of 30 months of referred infertility related (SD: 28.54). Patients underwent pre-operative assessment with physical examination, sperm analysis and Doppler ultrasound, and again the same assessment at least 3 months after surgery. We evaluated the following parameters: sperm concentration (millions/mL, CONC), percentage motility (a+b, MOT) and the percentage of morphologically typical spermatozoa (MOR). Univariate and Multivariate analysis were performed. The research of Pearson's coefficients was performed to test the correlation between sperm parameters and age, SG, CG. Semen specimens were evaluated according to WHO 1999 criteria. Mean CONC varied from 34.5 to 47.0 millions/mL (+12.5; p < 0.001); MOT from 27.2 to 34.5% (+7.3%; p < 0.001); and MOR from 44.0 to 47.6% (+3.6%; p = 0.001). Univariable and multivariable analysis of variance related to age showed no significant difference of parameters improvement. Pearson's correlation coefficient for pre-operative and post-operative sperm MOT related to patients' age was respectively −0.11 (p < 0.001) and −0.18 (p = 0.04). No other significance was found. Usefulness of treating infertile patients affected by varicocoele is confirmed: varicocoele correction leads to significant sperm parameters improvement. There is no evidence of different improvement related to patients' age. The decline in sperm motility related to age of the patients seems to be only age-dependent: the usefulness of treating patients affected by varicocoele is not influenced by their age: treatment should also be offered to older patients.
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    ABSTRACT: Objective To evaluate the outcome of microsurgical varicocelectomy in infertile men with severe oligozoospermia and to identify the predictive parameters associated with the efficacy of microsurgical varicocelectomy in this cohort of patients. Materials and Methods This study included 102 consecutive severe oligozoospermic patients who underwent microsurgical varicocelectomy between 2000 and 2013. The significance of several parameters as predictors of response to microsurgical varicocelectomy was evaluated using univariate and multivariate analyses. Responders were defined as those who fulfilled the following criteria: (1) sperm motility rate improved after surgery and (2) sperm concentration increased from <1 × 106/mL to ≥5 × 106/mL or from 1−5 × 106/mL to ≥10 × 106/mL. Results After the mean postoperative observation period of 8.2 months, the mean sperm concentration increased from 2.4 to 11.6 million/mL (P <.001), and the mean sperm motility improved from 32.8% to 42.2% (P = .0024). There were no significant differences in the levels of hormonal parameters between the preoperative and postoperative measurements. Of the 102 patients, 42 (41.1%) were determined to be responders, and the wives of 17 (16.7%) conceived naturally. Univariate analysis identified preoperative sperm concentration (≥2.0 vs <2.0 million/mL) and laterality of varicocele (bilateral vs unilateral) as significant predictors of response to varicocelectomy. Only preoperative sperm concentration appeared to be independently related to the efficacy of varicocelectomy in men with severe oligozoospermia on multivariate analysis. Conclusion Varicocelectomy may improve the sperm quality and fertility potential in men with severe oligozoospermia, particularly for those with relatively high sperm concentration.
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Jun 5, 2014