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Varicocele and male infertility

Key Points

  • Varicoceles have detrimental effects on semen quality, sperm function, and pregnancy outcomes in some men

  • Oxidative stress seems to have a central role in the pathogenesis of varicocele-induced infertility

  • Current evidence supports beneficial effects of varicocelectomy on semen parameters, sperm function, and pregnancy outcomes in men from couples with documented infertility with clinical varicoceles and affected semen parameters

  • The optimal technique for performing varicocelectomy is a microsurgical approach, owing to reduced complication rates and increased pregnancy rates compared with other techniques

  • Current evidence supports varicocele repair in adolescents with clinical varicoceles when progressive testicular growth retardation and/or impaired semen quality is observed

  • Varicocelectomy might have beneficial effects on pregnancy outcomes following assisted reproduction>

Abstract

The link between varicoceles and male infertility has been a matter of debate for more than half a century. Varicocele is considered the most common correctable cause of male infertility, but some men with varicoceles are able to father children, even without intervention. In addition, improvements in semen quality after varicocelectomy do not always result in spontaneous pregnancy. Studies regarding possible pathophysiological mechanisms behind varicocele-induced infertility have tried to address these controversies. Oxidative stress seems to be a central mechanism; however, no single theory is able to explain the differential effect of varicoceles on infertility. As a consequence, careful patient selection for treatment based on couple fertility status, varicocele grade, and semen quality is critical for achieving a chance of a subsequent pregnancy. A substantial amount of data on the effects of varicocelectomy has been gathered, but inadequate study design and considerable heterogeneity of available studies mean that these data are rarely conclusive. Current evidence suggests a beneficial effect of varicocelectomy on semen quality and pregnancy outcomes in couples with documented infertility only if the male partner has a clinically palpable varicocele and affected semen parameters.

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Figure 1: Anatomy of the venous drainage from the testes.
Figure 2: The central role of oxidative stress in the pathophysiology of varicocele induced male infertility.
Figure 3: Treatment algorithm for adult infertile men with varicoceles.

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C. F. S. J. researched data for the article and wrote the manuscript. M. F. and C. F. S. J. made substantial contributions to discussion of content. All authors reviewed and edited the manuscript before submission.

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Correspondence to Mikkel Fode.

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J.M.D. receives grant funding from Blue Cross Blue Shield of Michigan for his role in the Michigan Value Collaborative and Michigan Urological Surgery Improvement Collaborative and owns common stock in Lipocine. D.A.O is a consultant for Coloplast and Pfizer and receives research funding from Endo. J.S. is a consultant for Astellas, Neotract, and Pfizer, and is a shareholder of Multicept. M.F. is a consultant and speaker for Astellas. C.F.S.J and P.B.Ø. declare no competing interests.

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Jensen, C., Østergren, P., Dupree, J. et al. Varicocele and male infertility. Nat Rev Urol 14, 523–533 (2017). https://doi.org/10.1038/nrurol.2017.98

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