Varicocele

Abstract

There is probably no subject that has been more controversial in the area of male infertility than varicocele. Most non-urologist infertility specialists in the world are skeptical of the role of varicocele or varicocelectomy in the treatment of male infertility, especially since the advent of ICSI [1]. However many urologists strongly recommend varicocelectomy, and now in 2017, there is another push to reestablish this surgery for infertile couples with male factor infertility. The September 2017 issue of Fertility and Sterility was dedicated to varicocelectomy with all positive, and no negative, reviews [2]. It has been suggested that in addition to infertility, varicocele has a negative impact on Leydig cell function, testosterone level, and overall “male health,” and that varicocelectomy will raise testosterone levels and improve “overall male health” [3–5]. It has also been suggested that varicocelectomy improves the results of ART (assisted reproductive technology) even though most early papers on ICSI showed no relation of sperm parameters to success or failure [6–9]. However, another equally large and very similar cohort study showed no difference in success with ICSI in men with varicocele who underwent varicocelectomy than in men who did not [10]. Interestingly, the study which showed improvement was only when there were younger female partners, and not older female partners. To confuse things more, a meta-analysis of these studies concluded no improvement in pregnancy rate with varicocelectomy performed before ART but there was improvement in birth rate [6]. With azoospermia TESE cases there was only a “strong trend” toward improvement after varicocelectomy [6]. Because of this enthusiastic resurgence of interest in varicocelectomy, I would like to once again review previous literature to objectively evaluate whether it is appropriate to perform varicocelectomy for male infertility in the era of ICSI.