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Male infertility / Vericocele


No Help from Varicocele Repair

Male infertility is a condition that has many different causes. While most of the conditions reflect an abnormal semen analysis the pathways leading to semen abnormalities are not well understood. This is the case of scrotal varicocele. Varicocele is characterized by dilatation of the spermatic veins that surround the scrotum. When present, it is believed that varicocele affect the patient=s seminal characteristics by lowering the thermoregulatory mechanism of the testis. The testis in most animals to function properly must be about 5-6C below the normal body temperature. Several physiological and anatomic mechanisms are in place to ensure that testicular temperature is effectively below body temperature. One of the most common therapies in infertile men is surgical repair of varicocele in the scrotum. The logic behind is that removing a potential barrier for effective heat dissipation (varicocele) it is going to improve the seminal characteristics and thus lead to restoration of fertility.

Whether varicocele causes male infertility and whether surgical treatment (varicolectomy) influences the pregnancy rate are two highly controversial issues. Most studies of the effects of varicolectomy fertility have been retrospective and with inadequately controlled, poorly randomized, with low number of observations, or have used changes in semen analysis rather than pregnancy rate as end points. An improvement in semen characteristics does not mean an effective improvement on pregnancy rates. As an example, you as a patient may have 1-2 million sperm/ml. Even if you experience a 100% improvement (which is very unlikely), the sperm counts after varicolectomy may not be sufficient to initiate a pregnancy. One of the most compelling reports for the use of varicolectomy as a therapy for infertility was published in 1995. It indicated that 8/25 (44.4%) couples conceived within 12 months of surgery compared to 2/20 (10%) of couples with no surgery. However, the statistical analysis revealed that there was no significative effect of surgical intervention and that the differences observed were due to non-identified factors. While many more reports have been published in pro or against varicolectomy and no definitive answers have been provided to support the use of this surgical procedure, this intervention continues to be pushed by urologists as one of the main therapies for male infertility despite the lack of proven effectivity.

As the controversy continues, in 2003 two respected entities in the medical field published definitive blows against varicolectomies. Hopefully, the reports will put the controversy to rest. A systematic review of seven studies published in the respected British medical journal, Lancet, indicated that the pregnancy rates for treated (varicolectomy) and untreated patients were 21 and 19% respectively. The authors concluded that Avaricocele treatment was not effective in trials restricted to male subfertility with clinical varicocele, or in those that included men with subclinical varicocele or normal semen analysis@. Their final interpretation concludes that AVaricocele repair does not seem to be an effective treatment for male or unexplained subfertility@. The prestigious male-infertilityJournal of the American Medical Association (JAMA) endorses the Lancet study in a brief but concise comment (J. Stephenson JAMA June 2003)

The real danger of using ineffective therapies for the treatment of infertility resides not only on the fact that there is no benefit associated to the cost or risk of surgery. Something else of more importance is at risk: the ability of the woman to have her own genetic children. The time a couple is wasting on ineffective therapies may work against them especially in couples in their mid 30s or older. The biological clock is ticking in women over 35. Each day a couple spends without a baby is a day that will never be recuperated. Ineffective therapies very seldom result in favorable outcomes, why waste your time and money and increase the probability of having a childless life?

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