Treatment outcome after varicocelectomy: A critical analysis

After extensively reviewing the literature that addresses the efficacy of varicocelectomy it is apparent that the extant data are flawed because of inappropriate study design and reporting. These difficulties are compounded by an inadequate understanding of the pathophysiology of the varicocele and the complexities intrinsic to the study of reproduction. Varicocelectomy does, indeed, appear to have a beneficial effect on sperm density. This effect seems more pronounced when initial semen densities are greater than 10 million/mL. Conversely, a 'ceiling effect' or less of a response may occur when preoperative sperm densities are greater than 40 million/mL. Although anecdotal reports suggest that varicocelectomy may be of benefit even to the azoospermic individual, we do not ascribe to this approach. Motility and morphology may improve significantly after varicocelectomy when an associated rise in density has occurred. Isolated improvements in either of these parameters have also been observed. Simultaneous improvements in density and morphology, however, have not been reported unless a concurrent significant improvement in semen density occurs. In spite of the occasional study which indicates that varicocelectomy does not improve fertility, the preponderance of the literature does in fact support a favorable effect. After carefully analyzing the design and outcome of the studies reviewed, it is clear that a definitive statement concerning the efficacy of varicocelectomy cannot be made. This therapeutic dilemma can be resolved only by a well-designed prospective, randomized, controlled study that examines the impact of varicocelectomy on seminal parameters, sperm function tests, and the pregnancy rates in couples evaluated by stringent protocols. Patients should be stratified according to seminal parameters and age. We conclude as we began: Varicocelectomy remains an important treatment of male factor infertility.