Report on varicocele and infertility: a committee opinion

doi:10.1016/j.fertnstert.2014.10.007

Fertility and Sterility

Volume 102, Issue 6, December 2014, Pages 1556-1560

https://doi.org/10.1016/j.fertnstert.2014.10.007 Get rights and content

This document discusses the evaluation and management of varicoceles in the male partners of infertile couples, and presents the controversies and recommendations regarding this condition. This document replaces the ASRM Practice Committee document titled “Report on Varicocele and Infertility,” last published in 2008, and was developed in conjunction with the Society for Male Reproduction and Urology (Fertil Steril 2008;90:S247–9).

Section snippets

Detection of varicoceles

Evaluation of a male patient with infertility should include a careful medical and reproductive history, a physical examination, and at least two semen analyses. The physical examination should be performed with the patient in both the upright and recumbent positions. A palpable varicocele feels like a “bag of worms” and disappears or is very significantly reduced when the patient is recumbent. When a suspected varicocele is not clearly palpable, the scrotum should be examined while the patient

Indications for treatment of a varicocele

When the male partner of a couple attempting to conceive has a varicocele, treatment of the varicocele should be considered when most or all of the following conditions are met: [1] the varicocele is palpable on physical examination of the scrotum; [2] the couple has known infertility; [3] the female partner has normal fertility or a potentially treatable cause of infertility, and time to conception is not a concern; and [4] the male partner has abnormal semen parameters. Varicocele treatment

Management considerations

Varicocele repair, intrauterine insemination (IUI), and in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI) are options for the management of couples with male factor infertility associated with a varicocele. The decision to proceed with any of these management options is influenced by a number of factors. Varicocele repair has the potential to reverse a pathological condition, as opposed to IUI or IVF-ICSI, which are treatments that circumvent abnormal semen parameters and are

Treatment of varicoceles

There are two approaches to varicocele repair: surgery and percutaneous embolization. Surgical repair of a varicocele may be accomplished by various open surgical methods, including retroperitoneal, inguinal, and subinguinal approaches, or by laparoscopy. Percutaneous embolization treatment of a varicocele is accomplished by percutaneous embolization of the refluxing internal spermatic vein(s). None of these methods has been proven superior to the others in its ability to improve fertility,

Results of varicocele treatment

Surgical treatment successfully eliminates over 90% of varicoceles, with some series reporting over 99% success (20). Improvement in semen parameters after varicocele repair is somewhat difficult to measure, as there is no standard definition for what constitutes significant improvement. Furthermore, improvement needs to be interpreted in the context of the presurgical and postsurgical parameters. Most studies have reported that semen quality improves in a majority of patients after varicocele

Follow-up evaluation

Patients should be evaluated after varicocele treatment for persistence or recurrence of the varicocele. If the varicocele persists or recurs, internal spermatic venography may be performed to identify the site of persistent venous reflux and be followed by either surgical ligation or percutaneous embolization of the refluxing veins. Semen analyses should be performed at approximately 3-month intervals during the first year after varicocele treatment or until pregnancy is achieved. Intrauterine

Summary

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The diagnosis of varicoceles is based primarily on physical examination.
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Imaging studies are not indicated for the standard evaluation unless physical examination is inconclusive.
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Only clinically palpable varicoceles have been clearly associated with infertility.
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Adolescents and young men not actively trying to conceive who have a varicocele and objective evidence of reduced ipsilateral testicular size may be offered varicocele repair.
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Treatment options include surgical approaches or percutaneous

Conclusions

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Treatment of a clinically palpable varicocele may be offered to the male partner of an infertile couple when there is evidence of abnormal semen parameters and minimal/no identified female factor, including consideration of age and ovarian reserve.
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In vitro fertilization with or without ICSI may be considered the primary treatment option when such treatment is required to treat a female factor, regardless of the presence of varicocele and abnormal semen parameters.
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The treating physician's

Acknowledgments

This report was developed under the direction of the Practice Committee of the American Society for Reproductive Medicine and the Society for Male Reproduction and Urology as a service to its members and other practicing clinicians. Although this document reflects appropriate management of a problem encountered in the practice of reproductive medicine, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be

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Cited by (158)

Varicocele and male infertility
2023, Progres en Urologie
La varicocèle est la plus fréquente cause corrigible d’infertilité masculine. Elle a fait l’objet de recommandations récentes du Comité d’andrologie et de médecine sexuelle (CAMS) de l’Association française d’urologie (AFU). Depuis, la littérature a apporté des éléments supplémentaires. Cette revue réévaluera de manière exhaustive les indications actuelles du traitement des varicocèles, et reviendra sur les questions contemporaines au regard des avancées actuelles.
Réactualisation de la recherche bibliographique effectuée dans le cadre des recommandations du CAMS sur la période entre 2020 et 2023.
La varicocélectomie microchirurgicale sub-inguinale demeure le traitement chirurgical de référence pour les hommes infertiles présentant une varicocèle clinique et des paramètres spermatiques anormaux. Elle offre des taux de récidive inférieurs à 4 %. Elle améliore significativement les taux de naissances vivantes et de grossesse à la fois naturellement et par fécondation in vitro, ainsi que la numération, la mobilité totale et progressive, la morphologie et le taux de fragmentation de l’ADN des spermatozoïdes. Au total, elle modifie la stratégie en aide médicale à la procréation (AMP) dans environ un cas sur deux. Le grade et la bilatéralité de la varicocèle sont prédictifs de l’amélioration des paramètres spermatiques et du taux de grossesse. Il n’est pas recommandé de traiter les varicocèles infracliniques. Les complications sont rares, notamment les hydrocèles (0,5 %), les atrophies testiculaires unilatérales par atteinte artérielle (1/1000), les hématomes, retards de cicatrisation, et douleurs postopératoires. L’embolisation rétrograde est une alternative à la chirurgie.
L’urologue doit chaque fois que possible présenter et discuter avec l’équipe d’AMP et le patient les possibilités de traitement d’une varicocèle dans une approche personnalisée.
Varicocele is the most common correctable cause of male infertility. It was the subject of recent Association française d’urologie (AFU) Comité d’andrologie et de médecine sexuelle (CAMS) recommendations. Since then, the literature has provided additional information. This review will comprehensively reassess current indications for the treatment of varicocele, and revisit contemporary issues in the light of current advances.
Update of the literature search carried out as part of the CAMS recommendations for the period between 2020 and 2023.
Microsurgical sub-inguinal varicocelectomy remains the surgical treatment of choice for infertile men with clinical varicocele and abnormal sperm parameters. It offers recurrence rates of less than 4%. It significantly improves both natural and in vitro fertilization live birth and pregnancy rates, as well as sperm count, total and progressive motility, morphology and DNA fragmentation rates. All in all, it modifies the MPA strategy in around one in two cases. Varicocele grade and bilaterality are predictive of improved sperm parameters and pregnancy rate. Treatment of subclinical varicocele is not recommended. Complications are rare, notably hydroceles (0.5%), unilateral testicular atrophy due to arterial damage (1/1000), hematomas, delayed healing and postoperative pain. Retrograde embolization is an alternative to surgery.
Whenever possible, the urologist should present and discuss treatment options for varicocele with the MPA team and the patient, taking a personalized approach.
Understanding the impact of varicocele on sperm capacitation
2023, F and S Science
To study the relationship between the seminal sample quality of men with varicocele and sperm capacitation.
Cross-sectional observational study.
Academic hospital.
Seventy-six men (19 control and 57 with varicocele) were analyzed.
Semen samples were submitted to a discontinuous density gradient for sperm selection. Sperm capacitation was induced using a human tubal fluid medium supplemented with bovine serum albumin.
After capacitation induction, the sperm were assessed by capacitation state, computer-assisted sperm motility, mitochondrial activity, membrane integrity, acrosome reaction, and intracellular oxidative stress.
The capacitation period increased sperm motility, showing an increase in the average path velocity and a decrease in the straightness compared with sperm before capacitation (paired analysis). After capacitation, the rate of capacitated sperm, motility, and mitochondrial activity showed differences between groups (control and varicocele). The varicocele group showed lower mitochondrial activity and capacitation than the control group. On the other hand, no significant differences were observed in the other variables evaluated.
Varicocele men showed less viable sperm and mitochondrial activity than control men after capacitation sperm. The induction of capacitation altered motility by increasing path velocity and decreasing straightness in all of the studied groups, evidencing the occurrence of hyperactivation.
Case report of testicular failure and azoospermia after antegrade embolization of varicocele: A rare complication
2023, International Journal of Surgery Case Reports
Varicocele is a common condition affecting males of reproductive age and accounting for the most frequent cause of secondary infertility in males.
A young male presented with second infertility and bilateral varicoceles and underwent antegrade angioembolization. He developed testicular ischemia and testicular failure with new onset hypogonadism and cryptozoospermia.
Antegrade embolization is a valid option in patients with varicoceles but has its own unique risks of complications.
The fertility evaluation of the male partner
2023, Handbook of Current and Novel Protocols for the Treatment of Infertility
This chapter focuses on the evaluation of male infertility. It starts with the background and etiologic factors for male infertility. Subsequently, the chapter discusses the history and physical examinations components in males presenting for infertility evaluation. Furthermore, the chapter focuses on the latest recommendations, including interpretations and indications of various tests utilized in infertile males, including semen analysis, hormonal evaluation, and genetic screening. In addition, we discuss the differentiation between obstructive and nonobstructive causes of infertility and how to approach both disease entities. We also discuss ancillary tests used in specific conditions causing infertility such as congenital bilateral absence of the vas deferens, ejaculatory duct obstruction, and recurrent pregnancy loss. Finally, we discuss the association between infertility and general health.
Treatment of subclinical varicocele with acupuncture: A case report
2022, Explore
Varicocele is a vascular lesion characterized by abnormal dilatation and/or tortuosity of the veins of the pampiniform plexus, which sometimes manifests as chronic, dull pain in the scrotum, testicle or inguinal area. Subclinical varicocele (SCV) is as an early phase in the progression of its clinical analog. Given the lack of relevant studies on treatment strategies, no conclusive answer exists regarding how SCV should be managed. In this case report, a 40-year-old male patient visited our acupuncture outpatient clinic for left-sided scrotal pain and heaviness caused by SCV. After ten sessions of acupuncture treatments (acupuncture was performed at Zhongji (CV3), Guanyuan (CV4), qihai (CV6) and bilateral Guilai (ST29), Hegu (LI4), Taichong (LR3), Zusanli (ST36), Sanyinjiao (SP6), with electroacupuncture (EA) stimulation at Qihai (CV6) and Zhongji (CV3) as well as Guilai (ST29) on both sides), the patient was symptom-free. More unexpectedly, ultrasound reexamination showed no obvious abnormalities in bilateral spermatic veins. From this case, we conclude that acupuncture may be an effective alternative therapy for SCV treatment.
Characterization of varicocele-induced animal models: Potential role of inflammasome complex in the varicocele pathophysiology
2022, Journal of Reproductive Immunology
Citation Excerpt :
Varicocele has an average prevalence of 15 % among men of reproductive age and, according to Clavijo et al. (2017), these values were the same since the first study more than 30 years ago (Saypol, 1981; Clavijo et al., 2017). In addition, according to the American Society for Reproductive Medicine (ASRM) report (Practice Committee of the American Society for Reproductive Medicine and Society for Male Reproduction and Urology, 2014), 40 % of infertile men have varicocele. Varicocele tends to develop at the beginning of puberty, already being observed frequently among adolescents aged 14 or less (Alsaikhan et al., 2016).
Varicocele mechanisms and its impact in testicular dysfunction has been studied in order to understand the pathophysiology involved in this disease. However, study designs using testicular tissues from varicocele patients are restricted due to ethical limitations. Therefore, the use of animal models, mainly rats, that mimics varicocele and its effects is an option to develop new approaches. The surgical technique, that induces the varicocele in rats, is based on the partial obstruction of the left renal vein, leading to a dilation in the left spermatic vein and consequently to the pampiniform plexus, resulting in varicocele-induced condition. Thus, the study of the cellular and molecular mechanisms involved in varicocele development can be addressed in depth. Besides the animal model goal to uncover the exact varicocele pathophysiology, varicocele induced models are the best options to develop new non-surgical and less invasive therapies. Various animal model studies designed and investigated antioxidant and anti-inflammatory agents to face varicocele conditions. Minding this fact, we tried to discuss a newly uncovered complex in varicocele condition, known as inflammasome complex. Taking into consideration the possible inflammatory state present in varicocele, the inflammasome complex has been proposed to be involved in the pathophysiology of this disease.

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ASRM pagesReport on varicocele and infertility: a committee opinion

Section snippets

Detection of varicoceles

Indications for treatment of a varicocele

Management considerations

Treatment of varicoceles

Results of varicocele treatment

Follow-up evaluation

Summary

Conclusions

Acknowledgments

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J Urol

Fertil Steril

J Urol

J Urol

J Urol

Urology

Urol Clin North Am

Fertil Steril

Fertil Steril

Urology

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ASRM pages
Report on varicocele and infertility: a committee opinion