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SPECIAL PROBLEMS IN THE TREATMENT OF MALE INFERTILITY

VARICOCELE

Introduction

Varicocele is a common abnormality (see above Andrological investigations and spermatology) with the following andrological implications:

? Failure of ipsilateral testicular growth and development

? Symptoms of pain and discomfort

? Infertility

Classification

The following classification of varicocele [1,2] is useful in clinical practice:

Subclinical: Not palpable or visible at rest or during Valsalva manoeuvre, but demonstrable by special

tests (finding of reflux on Doppler examination) [3]
Grade 1: Palpable during Valsalva manoeuvre but not otherwise

Grade 2: Palpable at rest, but not visible

Grade 3: Visible and palpable at rest

6.1.3 Diagnosis

The diagnosis of varicocele has been defined by the WHO [2]. The consensus is that diagnostic procedures and classification of a varicocele including analysis have to follow these accepted criteria [2].

The diagnosis of varicocele is made by clinical examination and may be confirmed by colour Doppler analysis. In centres where treatment is performed by antegrade or retrograde sclerotherapy or embolization, the diagnosis is additionally confirmed by X-ray.

6.1.4 Basic considerations

1. Varicocele is a physical abnormality present in 2-22% of the adult male population [4,5]. It is more
common in men of infertile marriages, affecting 25% of those with abnormal semen analysis [6].

2. The incidence of pain and discomfort associated with varicocele is 2-10% [7]. Treatment to relieve
symptoms is often recommended, but there are few outcome studies; however, most urologists accept
discomfort as a valid indication.

3. The exact association between reduced male fertility and varicocele is unknown, but analysis of the
WHO data [8] clearly indicates that varicocele is related to semen abnormalities, decreased testicular
volume and decline in Leydig cell function.

4. Two prospective randomized studies show increased ipsi- and contralateral testis growth in adolescents
who received varicocele treatment compared with those who did not [9,10]. A cohort follow-up study
involving serial measurement of testicular size in growing children indicated arrest of testicular
development coincident with development of varicocele and catch-up to the growth percentile after
treatment [11].

5. A series of studies suggested that altered endocrine profiles in men with varicocele (exaggerated
response to releasing factor) might predict those who would benefit from treatment [12,13].

6. Five prospective randomized studies of varicocele treatment in adults gave conflicting results [6,14-18],
the largest of them indicating benefit [16,18]. It involved 10 centres, was externally randomized and

included men of infertile couples who had moderate oligozoospermia (5-20 x 107ml_) and grade II or III varicocele. Immediate therapy was shown to be significantly more effective than delaying treatment for 1 year with regard to pregnancy achievement and pregnancy rate per cycle (fecundability). However, meta-analysis of the five trials indicated no benefit (the common odds ratio was 0.85% (95% Cl 0.49-1.45) [19].

7. There is one prospective randomized study of treatment of subclinical varicocele, which failed to
indicate fertility benefit from therapy [20].

8. Analysis of the large WHO infertility study [21] indicates that there is an excess of couples where both
partners have factors associated with reduced fertility compared with the expected rate of coincidence
in the general population. This implies that a minor cause of impaired fertility, such as varicocele, will
only be manifest in couples where the female partner also has reduced fertility.

Treatment of varicocele to achieve pregnancy in infertile partnerships remains controversial and all investiga?tions to date have been subject to criticism. Further investigations are needed, particularly for younger couples.

6.1.5 Treatment

Several treatment modalities can be chosen (Table 10).

The type of intervention is mainly dependent on the therapist's experience. The consensus is that although laparascopic varicocelectomy is feasible, it needs to be justified in terms of cost effectiveness.

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