I-2: Varicocele and Male Infertility: A Clinical Dilemma

Background: To date, impact of varicocelectomy on semen parameters is controversial mainly because clear preoperative selection criteria of patients to be submitted to varicocele surgery are still lacking. A comprehensive review on varicocele pathophysiology, and indications to varicocelectomy according to controlled studies and methanalises from literature and the Guidelines of the Scientific Societies will be presented. In our study we considered the characteristics of spermatic venous reflux, detected with Color Doppler Ultrasound (CDU), with the aim of finding a criterion for selecting infertile men candidate to varicocelectomy in order to significantly improve their semen quality. Materials and Methods: Since 1983 our Group designed a prospective rigorous protocol study on infertile patients affected with varicocele, based on two preoperative semen analyses (basal and repeated three months later), a preoperative CDU in standing position to assess venous reflux along the spermatic and the pampiniform plexus veins, surgical varicocelectomy, a postoperative CDU (one month after varicocelectomy) for reflux recurrence exclusion, and two postoperative semen analyses (respectively 15 and 23 weeks after varicocelectomy). Semen samples were analyzed according to the WHO criteria in force at that specific time, and sperm concentration, forward motility and morphology were recorded. According to the CDU, venous reflux was classified as basal continuous when, in standing position, a spontaneous reflux independent from respiration and increasing during Valsalva manoeuvre was registered, and basal intermittent, when, under the same conditions, a discontinuous reflux synchronous with breath movements was documented. At the end, out of 1.775 infertile patients, 360 met all strict inclusion criteria and were considered for the study: 319 patients showed continuous reflux (group A), whereas 41 had intermittent reflux (group B). Results: Preoperatively, compared to the group A, group B showed both higher sperm concentration (p = 0.03) and morphology (p < 0.0001) without differences regarding sperm forward motility. After varicocelectomy, compared to the baseline, neither sperm concentration, nor sperm motility, nor sperm morphology improved in the group B, whereas all sperm parameters improved significantly 15 and 23 weeks after varicocelectomy in the group A (p < 0.0001). Conclusion: Preoperative semen parameters were found worst in infertile varicocele patients with a basal continuous reflux, and varicocelectomy improved significantly sperm quality only in this group of men; based on our results, infertile patients with a discontinuous reflux on CDU should not be routinely submitted to varicocelectomy.