[1] Yanagimachi R. Germ cell research: a personal perspective. Biol
Reprod 2009;80:204–18.
[2] Seandel M, Rafi S. Reproductive biology: in vitro sperm maturation.
Nature 2011;471:453–5.
Walter Cardona Maya
Grupo Reproduccio
´n, Universidad de Antioquia, Medellı´n, Colombia
E-mail address:
Re: Does Varicocele Repair Improve Male Infertility?
An Evidence-Based Perspective From a Randomized,
Controlled Trial
Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM
Eur Urol 2011;59:455–61
Experts’ summary:
In a prospective, nonmasked, randomized controlled trial, the
authors assessed the e±±icacy o± varicocelectomy with the
primary outcome o± spontaneous pregnancy
. The authors
examined men with primary or secondary in±ertility who
displayed clinical varicoceles on physical examination and
at least one impaired semen parameter on semen analysis.
Importantly, authors excluded men with subclinical or recur-
rent varicoceles or men with normal sperm parameters.
A total o± 150 men were randomized to either observa-
tion or a microscopic subinguinal varicocelectomy. Only 5
men were lost to ±ollow-up, leaving 145 ±or analysis. A±ter
12 mo o± ±ollow-up, 13.9% o± the observation group and
32.9% o± the treatment group had achieved pregnancy, with
overall improved odds (odds ratio [OR]: 3.04; 95% con±i-
dence interval [CI], 1.33–6.95) o± achieving pregnancy with
varicocelectomy. The authors ±ound a number needed to
treat o± 5.27 (95% CI, 1.55–8.99), which suggests that 5.27
men need to undergo varicocelectomy to achieve one
spontaneous pregnancy.
As a secondary outcome, the authors examined semen
parameters, including sperm concentration, motility, and
morphology, and ±ound signi±icant improvements in all
three parameters a±ter treatment. In contrast, no signi±icant
changes o± semen parameters ±rom baseline were ±ound in
the observation arm.
Experts’ comments:
Despite the ±act that numerous studies have demonstrated the
bene±it o± varicocele repair, many reports have been mired by
methodological limitations. In the era o± evidence-based med-
icine, physicians and patients o±ten demand robust proo± o±
e±±icacy. The most recent Cochrane review on varicocelectomy
showed no improvement in the odds o± pregnancy (OR: 1.10;
95% CI, 0.73–1.68) a±ter varicocele treatment
. The
Cochrane analysis pooled results o± randomized controlled
trials that assessed e±±icacy o± varicocele treatment, either
surgical varicocelectomy or percutaneous embolization. A
total o± eight studies were included in the meta-analysis,
which examined a total o± 607 men. Un±ortunately, trials that
included men with subclinical varicoceles as well as men with
normal semen analyses were included in the treatment arms
o± the analyzed studies, despite current practice o± discourag-
ing treatment o± such men. When the analysis was restricted
to include only the studies with men who possessed abnormal
semen parameters with clinical varicoceles, only three studies
remained. Although the statistical power was reduced, the OR
suggested a possible bene±it o± varicocele treatment, although
the CI was wide (OR: 2.08; 95% CI, 0.60–4.25).
Manyexpertshave criticized the Cochrane review±or both
its inclusion criteria and its outcome measures. The inclusion
o± trials that enrolled men with subclinical varicoceles and
with normal semen parameters—both groups that are known
not to bene±it ±rom varicocele treatment—weakens any
conclusions that could be reached by a meta-analysis
including such studies. Marmar et al
per±ormed a
systematic review o± pregnancy outcomes a±ter varicocele
treatment but included only studies o± men with palpable
varicoceles and abnormal semen parameters. Perhaps not
surprisingly, the authors ±ound signi±icantly increased odds
o± pregnancy a±ter varicocele treatment (OR: 2.87; 95% CI,
The current trial is not per±ect. The lack o± adequate
statistical methods, and a lack o± a time to event analysis ±or
both pregnancy and semen improvement all weakened the
study. Nevertheless, Abdel-Meguid and colleagues are to be
commended ±or continuing to explore a question ±or which
doubt exists in many minds and to improve the level o±
evidence that exists to help in±ertile men with varicoceles.
Conflicts of interest:
Dr. Lipschultz is a speaker and consultant ±or
Auxillium and AMS and a consultant ±or Repros. Dr. Eisenberg has nothing
to disclose.
[1] Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM. Does varicocele
repair improve male in±ertility? An evidence-based perspective ±rom
a randomized, controlled trial. Eur Urol 2011;59:455–61.
[2] Evers JH, Collins J, Clarke J. Surgery or embolisation ±or varicoceles in
sub±ertile men. Cochrane Database Syst Rev 2009, CD000479.
[3] Marmar JL, Agarwal A, Prabakaran S, et al. Reassessing the value o±
varicocelectomy as a treatment ±or male sub±ertility with a new
meta-analysis. Fertil Steril 2007;88:639–48.
Michael L. Eisenberg
, Larry I. Lipshultz
Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
*Corresponding author. Baylor College o± Medicine, Department o±
Urology, 6624 Fannin St., Suite 1700, Houston, TX 77030, USA.
E-mail address:
(M.L. Eisenberg)
EUROPEAN UROLOGY 60 (2011) 392–396