In a report online March 15 in the Journal of Urology, the authors note that varicocele is the most common cause of male infertility. The literature on the impact of varicocelectomy on fertility parameters is mixed and the optimal surgical approach is the subject of debate.
Dr. Stephan Madersbacher from Danube Hospital Vienna, Austria and colleagues searched the literature using MEDLINE and the Cochrane Library for articles published in the last 20 years that reported on sperm parameters before and after varicocelectomy.
They limited their analysis to studies with at least two semen analyses (before and 3 or more months after surgery) and that included patients older than age 19 years, with clinical subfertility and/or abnormal semen parameters and a clinically palpable varicocele.
A total of 14 articles met their criteria and were included in the analysis.
According to the authors, all three surgical techniques (high ligation, inguinal and subinguinal approach) led to “significant or highly significant postoperative improvement” in sperm count and motility, “with only slight numeric differences among the techniques. This difference did not reach statistical significance for sperm count (p =0.973) or sperm motility (p=0.372).
After high ligation surgery, sperm count increased, on average, by 10.85 million per mL (p=0.006) and motility by 6.80% (p<0.00001). Inguinal varicocelectomy led to an improvement in sperm count of 7.17 million per mL (p<0.0001) while motility changed by 9.44% (p =0.001). Subinguinal varicocelectomy provided an increase in sperm count of 9.75 million per mL (p=0.002) and sperm motility by 12.25% (p=0.001).
In terms of pregnancy rates, however, inguinal varicocelectomy had the advantage, yielding the highest pregnancy rate of 41.48% compared to 26.90% and 26.56% after high ligation and subinguinal varicocelectomy, respectively. The difference was statistically significant (p=0.035).
The authors say, “By following the current guidelines in terms of excluding patients with subclinical varicocele and by ruling out possible sources of bias, the acquired data provide the best available evidence.”