Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

Abstract

Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility. Materials and Methods: Materials and Methods: Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field. Results: Results: The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/ uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available. Conclusions: Conclusions: This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

Productivity Index in Clinical Andrology: Research Directions on High-Impact Topics and in Particular on Male Infertility

“…Conversely, the current available evidence does not seem to support the benefit of treating a subclinical varicocele or a bilateral varicocele that is not clinically significant [23]. Considering that varicocele is present in about 35% of patients with primary infertility and the controversy still present regarding its therapeutic management in the context of infertility [24], it is not surprising that the association between male infertility and varicocele is still being extensively investigated.…”

Dynamic contrast-enhanced MRI in the assessment of testicular perfusion in infertile men with clinical varicocele

“…Heat stress, reflux of adrenal or renal metabolites, testicular hypoxia and alterations in testicular extracellular fluid dynamics, accumulation of cadmium, and genetic and autoimmune disturbances may initiate OS. In addition, infertile men with varicocele have sperm DΝΑ damage, for which OS is considered one of the most important causative factors (1)(2)(3)(4)(5)(6)(7)(8).…”

“…Varicocele is defined as an abnormal dilation and tortuosity of the νeins of the pampiniform νenous plexus and the testicular veins, with continuous or intermittent reflux of the venous blood (1)(2)(3)(4)(5)(6)(7)(8). In De Medicina, published during the first century AD, a Roman nobleman, Cornelius Celsus credits the Greeks with the first description of a varicocele (9).…”

“…A clinical varicocele is found in about 25%-35% of men with primary infertility and up to 80% of cases with secondary infertility. However, there are still no reliable criteria to allow the identification of men who should be referred for therapy, to avoid reduced reproductive potential, which is met in only 20%-25% of cases with clinical varicocele (1)(2)(3)(4)(5)(6)(7)(8)10).…”

Current and promising methods of idiopathic male infertility treatment

“…Большинство клинически успешных подходов были направлены на лечение патологий с очевидным фенотипом [4]. Это терапия гипогонадотропного гипогонадизма [5], хирургическая коррекция варикоцеле [6], а также активное применение методов вспомогательных репродуктивных технологий, в том числе и методов хирургической экстракции сперматозоидов при азооспермии [7].…”