Is it worth repairing bilateral subclinical varicocele?

Abstract

Objective: Although the significance of subclinical varicocele is unclear, there is some literature to suggest that significant improvements in semen quality and pregnancy rates can be achieved after surgery. We asked the question whether it might be reasonable to repair men with bilateral subclinical varicocele, and review our findings from these here.Design: Retrospective study of a consecutive series of infertile patients with subclinical varicocele.Materials/Methods: The study included 33 infertile patients with abnormal semen parameters and bilateral subclinical varicoceles diagnosed by scrotal color Doppler ultrasonography. The ultrasound criteria included the presence of retrograde blood reflux into the internal spermatic vein with the diameter of vein >2.5 mm at rest in the supine position without a Valsalva maneuver. Preoperative clinical findings, hormones, pre- and postoperative semen parameters including Kruger strict morphology were obtained in all patients. All patients underwent bilateral microsurgical either inguinal or subinguinal varicocele repair. A positive response to varicocele repair was defined as a 50% increase in total motile sperm counts (TMC) in the ejaculate from preoperatively to postoperatively. Spontaneous pregnancies were also assessed in all patients. Paired t test was used to compare pre- and post-operative semen parameters.Results: The mean age of the patients was 30 ± 1.1 years (18–43). The mean duration of infertility was 3.6 ± 0.65 years (1–18). The mean diameter of the internal spermatic vein was 3.2 ± 0.17 mm on the left side, and 2.9 ± 0.14 mm on the right side. The response to varicocele repair was observed in 18 out of 33 patients (54.5%), and 9 out of 27 couples (33.3%) achieved spontaneous pregnancy with the mean time of 7.2 ± 1.5 months after the surgery. The mean TMC increased from 22.8 ± 7.2 million to 35.8 ± 8.3 million (p = 0.026), and the mean Kruger strict morphology (%) increased from 4.8 ± 1.7 to 6.3 ± 1.5 (p = 0.037), postoperatively. In addition, when the seminal response to surgery was compared between the responders and non-responders, there were no differences in the mean patients age, testicular volumes, infertility duration, preoperative serum FSH and free testosterone levels, the diameters of internal spermatic veins, preoperative sperm count/ml, WHO and Kruger strict morphologies.Conclusions: This data strongly suggest that semen quality significantly improves in a half of patients with bilateral subclinical varicocele after surgery. The degree of improvement in postoperative TMC and pregnancy rate approximates the results of palpable varicocele repair. Objective: Although the significance of subclinical varicocele is unclear, there is some literature to suggest that significant improvements in semen quality and pregnancy rates can be achieved after surgery. We asked the question whether it might be reasonable to repair men with bilateral subclinical varicocele, and review our findings from these here. Design: Retrospective study of a consecutive series of infertile patients with subclinical varicocele. Materials/Methods: The study included 33 infertile patients with abnormal semen parameters and bilateral subclinical varicoceles diagnosed by scrotal color Doppler ultrasonography. The ultrasound criteria included the presence of retrograde blood reflux into the internal spermatic vein with the diameter of vein >2.5 mm at rest in the supine position without a Valsalva maneuver. Preoperative clinical findings, hormones, pre- and postoperative semen parameters including Kruger strict morphology were obtained in all patients. All patients underwent bilateral microsurgical either inguinal or subinguinal varicocele repair. A positive response to varicocele repair was defined as a 50% increase in total motile sperm counts (TMC) in the ejaculate from preoperatively to postoperatively. Spontaneous pregnancies were also assessed in all patients. Paired t test was used to compare pre- and post-operative semen parameters. Results: The mean age of the patients was 30 ± 1.1 years (18–43). The mean duration of infertility was 3.6 ± 0.65 years (1–18). The mean diameter of the internal spermatic vein was 3.2 ± 0.17 mm on the left side, and 2.9 ± 0.14 mm on the right side. The response to varicocele repair was observed in 18 out of 33 patients (54.5%), and 9 out of 27 couples (33.3%) achieved spontaneous pregnancy with the mean time of 7.2 ± 1.5 months after the surgery. The mean TMC increased from 22.8 ± 7.2 million to 35.8 ± 8.3 million (p = 0.026), and the mean Kruger strict morphology (%) increased from 4.8 ± 1.7 to 6.3 ± 1.5 (p = 0.037), postoperatively. In addition, when the seminal response to surgery was compared between the responders and non-responders, there were no differences in the mean patients age, testicular volumes, infertility duration, preoperative serum FSH and free testosterone levels, the diameters of internal spermatic veins, preoperative sperm count/ml, WHO and Kruger strict morphologies. Conclusions: This data strongly suggest that semen quality significantly improves in a half of patients with bilateral subclinical varicocele after surgery. The degree of improvement in postoperative TMC and pregnancy rate approximates the results of palpable varicocele repair.