Page 146 - Remedial Andrology

I² = 0%) compared with their pre-operative levels. An analysis of surgery vs. untreated control results showed
that mean testosterone among hypogonadic patients increased by 105.65 ng/dL (95% CI: 77.99-133.32 ng/dL),
favouring varicocelectomy [1714]. However, results must be treated with caution and adequate cost-benefit
analysis must be undertaken to determine the risks and benefits of surgical intervention over testosterone
therapy in this setting. Although, varicocelectomy may be offered to hypogonadal men with clinically significant
varicoceles, patients must be advised that the full benefits of treatment in this setting must be further evaluated
with prospective RCTs.

10.4.3.3.4 Varicocelectomy for assisted reproductive technology and raised DNA fragmentation
Varicocelectomy can improve sperm DNA integrity, with a mean difference of -3.37% (95% CI: -2.65% to
-4.09%) [1710]. There is now increasing evidence that varicocele treatment may improve DNA fragmentation
and outcomes from ART [1709, 1710]. As a consequence, more recently it has been suggested that the
indications for varicocele intervention should be expanded to include men with raised DNA fragmentation.
If a patient has failed ART (e.g., failure of implantation, embryogenesis or recurrent pregnancy loss) there
is an argument that if DNA damage is raised, consideration could be given to varicocele intervention after
extensive counselling [1715], and exclusion of other causes of raised DNA fragmentation [1710, 1716]. The
dilemma is whether varicocele treatment is indicated in men with raised DNA fragmentation and normal semen
parameters.

In a meta-analysis of non-azoospermic infertile men with clinical varicocele by Estevez et al., four
retrospective studies were included of men undergoing ICSI, and included 870 cycles (438 subjected to ICSI
with prior varicocelectomy, and 432 without prior varicocelectomy). There was a significant increase in the
2
clinical pregnancy rates (OR = 1.59, 95% CI: 1.19-2.12, I = 25%) and live birth rates (OR = 2.17, 95% CI:
2
1.55-3.06, I = 0%) in the varicocelectomy group compared to the group subjected to ICSI without previous
varicocelectomy. A further study evaluated the effects of varicocele repair and its impact on pregnancy
and live birth rates in infertile couples undergoing ART in male partners with oligo-azoospermia or azoospermia
and a varicocele [1709]. In 1,241 patients, a meta-analysis demonstrated that varicocelectomy improved
live birth rates for the oligospermic (OR = 1.699) men and combined oligo-azoospermic/azoospermic
groups (OR = 1.761). Pregnancy rates were higher in the azoospermic group (OR = 2.336) and combined
oligo-azoospermic/azoospermic groups (OR = 1.760). Live birth rates were higher for patients undergoing IUI
after intervention (OR = 8.360).

10.4.3.4 Disease management
Several treatments are available for varicocele (Table 41). Current evidence indicates that microsurgical
varicocelectomy is the most effective among the different varicocelectomy techniques [1710, 1717].
Unfortunately, there are no large prospective RCTs comparing the efficacy of the various interventions for
varicocele. However, microsurgical repair results in fewer complications and lower recurrence rates compared
to the other techniques based upon case series [1718]. This procedure, however, requires microsurgical
training. The various other techniques are still considered viable options, although recurrences and hydrocele
formation appear to be higher [1719].

Radiological techniques (sclerotherapy and embolisation) are minimally invasive widely used approaches,
although higher recurrence rates compared to microscopic varicocelectomy have been reported (4-27%)
[1694]. Robot-assisted varicocelectomy has a similar success rate compared to the microscopic
varicocelectomy technique, although larger prospective randomised studies are needed to establish the most
effective method [1720-1722].

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