The effect of magnified bilateral varicocele ligation on semen quality and the natural paternity rate in subfertile men, based on the sum of varicocele grading

OBJECTIVE To evaluate the effect of magnified bilateral varicocele ligation on the semen quality and natural paternity rate in subfertile men, based on the sum of varicocele grading. PATIENTS AND METHODS In a prospective longitudinal study, 78 patients (mean age 36.5 years, range 21-56) with a total of 156 varicoceles underwent bilateral varicocele ligation. Patients included had bilateral, primary and clinically palpable varicoceles, with a normal hormonal profile and abnormal semen; patients excluded had unilateral varicocele, or were recurrent cases, had infraclinical varicocele or had a genetic abnormality. Patients were classified into five groups (A-E), based on the findings of a physical examination; A included 13 patients with grade sum II (I + I), B included 21 with grade sum III (II + I), C included 25 with grade sum IV (II + II) or (III + I), D included 11 with grade sum V (III + II) and E included eight with grade sum VI (III + III). The follow-up was scheduled at 3, 6 and 12 months to assess semen variables and the natural paternity rate; 16 patients continued to a 36-month follow-up. Data were analysed statistically using a paired t-test to compare the mean sperm variables before and after surgery, with P < 0.05 considered to indicate significant differences. RESULTS Of the 78 patients, 74 completed the follow-up at 3 months and only seven missed the 6-month follow-up. Overall, the mean sperm density, total sperm motility and sperm morphology increased from 13.44 to 26.48 × 10(6)/mL, 27.4% to 53% and 41.4% to 65.0%, respectively; the differences were statistically significant for all variables (P < 0.001). For each group separately there were significant improvements for both sperm density and motility, but for sperm morphology there were significant improvements in all groups except E, where the improvement was not correlated with those in the other groups. The paternity rate (by natural pregnancy) at 2 years was 26.9%, and this increased to 41% within 3 years. CONCLUSION Magnified bilateral varicocele ligation based on the sum of varicocele grading significantly improved semen quality and the natural paternity rate in subfertile men.