Surgery or embolisation for varicoceles in subfertile men

Evers J(LH, Collins J, Clarke J

Published Online:

November 10, 2010

No evidence that treatment of varicoceles in men from couples with otherwise unexplained subfertility improves pregnancy rates

Varicocele is a dilatation (enlargement) of the veins along the spermatic cord (the cord suspending the testis) in the scrotum. Dilatation occurs when valves within the veins along the spermatic cord obstruct normal blood flow, causing a backup of blood. The mechanisms by which varicoceles would affect fertility have not yet been explained, and neither have the mechanisms by which surgical treatment of the varicoceles might restore fertility. This review found no increase in pregnancy rates of varicoceles treatment compared to no treatment in subfertile couples, in whom varicoceles in the man is the only abnormal finding. (Synopsis prepared by Review Group)

Abstract (click to read)

Background:

A varicoceles is a meshwork of distended blood vessels in the scrotum, usually left-sided, due to dilatation of the spermatic vein. Although the concept that varicoceles causes, and varicocelectomy cures, male subfertility has been around for almost fifty years, the mechanisms by which varicoceles would affect fertility have not yet been satisfactorily explained, and neither have the mechanisms by which varicocelectomy would restore fertility. Furthermore, it has been questioned whether a causal relation exists at all between the distension of the pampiniform plexus and impairment of fertility.

Objectives:

To evaluate the effect of varicoceles treatment on pregnancy rate in subfertile couples.

Search strategy:

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (12 Sept 2003 and October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004 and Issue 4, 2007), MEDLINE (January 1966 to October 2007), EMBASE (January 1985 to October 2007) and reference lists of articles. In addition, we handsearched specialist journals in the field from their first issue until 2007. We also checked cross-references, references from review articles and contacted researchers in the field.

Selection criteria:

Randomised controlled trials (RCTs) were included if they were relevant to the clinical question posed, if they reported pregnancy rates as an outcome measure, and if they reported data in treated (surgical ligation or radiological embolisation of the internal spermatic vein) and untreated groups.

Data collection and analysis:

Nine studies met the inclusion criteria for the original review. One was an extension of a previously published study, which left eight studies for analysis. All eight only included men from couples with subfertility problems; one excluded men with sperm counts less than 5 million per mL and one men with sperm counts less than 2 million per mL, with or without progressive motility of less than 10%. Two trials involving clinical varicoceles included some men with normal semen analysis. Three studies specifically addressed only men with subclinical varicoceles. Two authors independently screened potentially relevant trials. Any differences of opinion were resolved by consensus (none occurred for this review). Studies were excluded from meta-analysis if they made comparisons other than those specified above.

Main results:

The combined Peto odds ratio (OR) of the eight studies is 1.10 (95%CI 0.73 to 1.68), indicating no benefit of varicoceles treatment over expectant management in subfertile couples in whom varicoceles in the man is the only abnormal finding.

Authors' conclusions:

There is no evidence that treatment of varicoceles in men from couples with otherwise unexplained subfertility improves the couple's chance of conception.

This record should be cited as:

Evers J(LH, Collins J, Clarke J. Surgery or embolization for varicoceles in subfertile men. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000479. DOI: 10.1002/14651858.CD000479.pub4

Assessed as up to date:

January 15, 2008

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Primary Review Group:

Menstrual Disorders and Subfertility Group

Health topics:

Gynaecology > Subfertility > Female: other

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Surgery or embolisation for varicoceles in subfertile men

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