Initial experience with robot-assisted varicocelectomy

Aim： To determine if robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic inguinal varicocelectomy. Methods： Eight patients aged 29.1 ± 12.5 years underwent microscopic subinguinal varicocelectomies： seven patients with left-sided repair, and one patient with bilateral repair. Eight patients aged 22.0 ±8.0 years underwent robot-assisted varicocelectomies： seven patients with left-sided repair and one patient with bilateral repair. Results： The average operative time for microscopic inguinal varicocelectomy was 73.9 ±12.2 min, whereas the robot-assisted technique took 71.1± 21.1 min. There were no difficulties in identifying and isolating vessels and the vas deferens with robot-assisted subinguinal varicocelectomy. Hand tremor was eliminated using the robotic procedure. Patients who underwent either microscopic or robot-assisted varicocelectomies were able to resume daily activities on the day of surgery and full activities within 2 weeks. There were no complications or recurrences of varicocele. Conclusion： From our experience, compared to microscopic surgery, robot-assisted varicocelectomy can be safely and effectively performed, with the added benefit of eliminating hand tremor.

Microsurgical varicocelectomy： a review

Varicocelectomy is the most commonly performed surgical procedure for the treatment of male infertility. Although several different techniques for varicocele repair have been described in the literature, microsurgical varicocelectomy performed through a subinguinal or inguinal incision is recognized as the gold-standard approach for varicocelectomy, due to high success rates with minimal complications. Standard indications for varicocelectomy include palpable varicocele（s）, with one or more abnormal semen parameters, and, for the couple trying to conceive, in the setting of normal or correctable female infertility. However, varicocele repair is often recommended and undertaken for reasons other than infertility, including low serum testosterone, testicular pain, testicular hypotrophy and poor sperm DNA quality. This article reviews the technical aspects of microsurgical varicocelectomy, and its indications in adults and adolescents.

Loupe-assisted versus microscopic varicocelectomy： s there an intraoperative anatomic difference？

The aim of this study was to compare the intraoperative difference in anatomic details between Ioupe-assisted and microscopic varicocelectomy within the same spermatic cord. Between April 2011 and August 2011, 26 men with 33 sides containing grade 2-3 varicocele were enrolled in this study. First, one surgeon performed the open inguinal varicocelectomy under x 3.5 Ioupe magnification. The presumed vascular channels and lymphatics were isolated and marked without ligation. Another surgeon then microsurgically dissected and checked the same spermatic cord using an operating microscope to judge the results in terms of the ligation of the internal spermatic veins and the preservation of the arteries and lymphatics. There were significant differences in the average number of internal spermatic arteries （1.51 vs 0.97）, internal spermatic veins （5.70 vs 4.39） and lymphatics （3.52 vs 1.61） between the microscope and Ioupe-assisted procedures （P 〈 0.001, P 〈 0.001, P 〈 0.001, respectively）. Meanwhile, in varicocele repair with Ioupe magnification, an average of 1.30 β± 1.07 （43/33） internal spermatic veins per side were missed, among the overlooked veins, 1.12 ± 0.93 （37/33） were adhered to the preserved testicular artery, as well as 0.55 ± 0.79 lymphatics and 0.36 ± 0.55 arteries that were to be ligated. In conclusion, microscopic varicocelectomy could preserve more internal spermatic arteries and lymphatics and could ligate more veins than the Ioupe-assisted procedure. To some degree, Ioupe magnification is inadequate for the reliable identification and dissection of the tiny vessels of the spermatic cord, as most of the overlooked veins were adhered to the preserved testicular artery.

Effect of Varicocelectomy on Semen Parameters of Men Seeking Infertility Treatment in Tamale, Ghana

The study aimed to determine the effect of microsurgical sub-inguinal varicocelectomy on semen parameters among men seeking infertility treatment in Ghana. This was an intervention study conducted at Tamale Teaching Hospital in the Tamale Metropolis from September 2017 to August 2021. The study involves two groups;the surgery group (n = 75) and the observed group (n = 63). Duplicate semen samples (mean values adopted) were collected at the onset and assessed according to the criteria established by World Health Organization (WHO), 2010. Varicocelectomy was performed for the surgery group and no intervention was given to the observed group. The two groups were followed for 180 days and repeated semen samples were collected and analyzed. The data was computed using GraphPad Prism (v8.0) at an alpha of 0.05. All the men had varicocele and were aged between 46.0 and 67.0 years old. There was no difference between semen parameters among the two groups before the surgery. However, after 180 days of follow-up, all of the semen parameters significantly improved in the surgery group (p < 0.0001), while sperm concentration (p = 0.0068), progressive motility (p = 0.0281), and normal sperm morphology (p = 0.0015) decreased in the observed group. The surgery group had an overall percent increase in total sperm count (840.7%;p = 0.0197), sperm concentration (582.1%;p = 0.0125), total viable sperms (155.2%;p < 0.0001), and normal sperm morphology (110.9%;p < 0.0001) while immotile sperms (-51.71%;p < 0.0001) reduced. A pregnancy rate of 25.3% (19/75) was reported among the surgery group but none was reported among the observed group after 180 days. Microsurgical sub-inguinal varicocelectomy improves semen parameters and hence effective treatment of infertile men with a clinically palpable varicocele. It is recommended to use this choice for similar patients, however, further studies with a larger sample size are needed to provide more evidence to recommend this therapy.

Outpatient varicocelectomy performed under local anesthesia

Aim： To report a series of varicocelectomy performed under pure local anesthesia. Methods： From July 1988 to June 2003, a total of 575 patients, aged between 15 and 73 years, underwent high ligation of the internal spermatic vein for treatment of a varicocele testis under a regional block in which a precise injection of 0.8 % lidocaine solution was delivered to involved tissues after exact anatomical references were made. A 100-mm visual analog scale （VAS） was used to assess whether the pain level was acceptable. Results： The surgeries were bilateral in 52 cases, and unilateral in 523 cases. All were successfully performed on an outpatient basis except in the case of two patients, who were hospitalized because their surgeries required general anesthesia. Overall, 98.6 % （567/575） of men could go back to work by the end of the first post-operative week and only 8 （1.4 %） men reported feeling physical discomfort on the eighth day. The VAS scores varied from 11 mm to 41 mm with an average of （18.5 ± 11.3） mm that was regarded as tolerable. Conclusion： This study has shown varicocelectomy under local anesthesia to be possible, simple, effective, reliable and reproducible, and a safe method with minimal complications. It offers the advantages of more privacy, lower morbidity, with no notable adverse effects resulting from anesthesia, and a more rapid return to regular physical activity with minor complications.

Serum Total Testosterone Levels Pre- and Post-Subinguinal Microsurgical Varicocelectomy in Men with Clinical Varicoceles

Background: Varicocele is abnormal dilation and tortousity of the scrotal venous pampiniform plexus that drain blood from each testicle. Recently, it has been linked to low serum total testosterone (TT) levels by affecting the optimal functioning of the leydig cell via increasing the scrotal temperature. Varicocele repair has been found post-operatively to increase the serum levels of TT. This study looks at the pre and post-subinguinal microsurgical varicocelectomy serum TT levels in male patients with clinical varicocele. Methods: The study involved 88 male patients with clinical varicoceles who met the inclusion criteria. These patients after good history taking and physical examination had their serum TT levels measured pre varicocelectomy and 6 months post-subinguinal microsurgical varicocelectomy. The varicoceles were diagnosed by physical examination and use of scrotal color Doppler ultrasonography (US). Results: The number of patients with varicocele were 88 males. The mean age of the patients was 33.43 ± 7.82 years. There was isolated left varicocele in 57 (64.8%) patients and bilateral varicocele in 27 (30.7%) patients. Pre varicocelectomy, 61 (69.3%) patients had serum TT of between 100 - 290 nanogram/deciliter (ng/dl) and a mean value of 241 ± 0.91 ng/dl. Post varicocelectomy 56 (63.6%) patients had serum TT in the range of 300 - 490 ng/dl with a mean of 482 ± 2.87 ng/dl, showing a robust significant increase in the serum TT post-operatively (P < 0.001). Conclusion: There was statistically significant improvement in the serum TT levels with 55 (79%) patients exhibiting normalization of serum TT levels after subinguinal microsurgical varicocelectomy.

Effect of Varicocelectomy on Gonadal Function among Patients Reporting with Sexual Dysfunction in Ghana

Background: Long-standing varicocele is often associated with testicular hypoxia and that might worsen Leydig cell function, a significant risk factor for hypogonadism. This may affect both the secretory and endocrine functions of the testis. This study aims to determine the effect of microsurgical sub-inguinal varicocelectomy on gonadal function among men reporting sexual dysfunction in Ghana. Methods: This was an intervention study conducted at the Tamale Teaching Hospital from September 2017 to August 2021. A total of 103 participants were randomized into two groups;the surgery group (n = 52) and the observed group (n = 51). Venous blood samples were collected at baseline, varicocelectomy was performed for the surgery group, and no intervention was given to the other. Blood samples were subsequently collected at 12-, 24-, 36-, and 48-month intervals for assay of serum total testosterone, FSH, and LH. The data were analyzed in GraphPad Prism (v8.0) at an alpha value of 0.05. Results: All the participants had varicocele and were aged between 55.0 to 69.0 years old. At the baseline of the study, all participants presented with sexual dysfunction but a significant improvement (p Conclusions: Microsurgical sub-inguinal varicocelectomy improved gonadal function among varicocele patients reporting sexual dysfunction. It is recommended to use this choice for similar patients;however, these findings should be verified by a multi-institutional study to provide more evidence for this choice.

Laparoscopic Varicocelectomy: Results and Outcomes in a Single Center in Cameroon

Background and Objective: The optimal treatment for varicocele is still controversial. Although there are many treatment methods, none can be considered as the best therapeutic option. We present our initial laparoscopic varicocelectomy experience by describing the clinical aspects and evaluating the outcomes of this surgical procedure at the Centre medico-chirugicale d’urologie in Douala, Cameroon. Materials and Methods: This was a retrospective study carried out between January 2015 and December 2019 on 35 patients with symptomatic varicoceles who were treated for either testicular pain or infertility. All surgical procedures were performed via laparoscopy, with ligation of the spermatic vein using a hemlock clip in the retroperitoneal space. The patients were followed up for three months after surgery, and data were collected and analyzed to obtain results. Results: The study participants were aged 16 - 55 years, with a mean age of 36.11 ± 8.45 years. Infertility was the main presenting complaint. In 65.7% of cases, varicoceles were bilateral with testicular atrophy occurring in 26 patients (74.28%). The surgery duration ranged from 14 minutes to 60 minutes, with an average duration of 34.8 minutes. There was no case of conversion to open surgery. No major complications were observed and all patients were discharged the day after surgery. Three months after surgery, all patients stopped experiencing pain and semen parameters improved in 71.42% of the study participants, with 42.82% of them impregnating their partners. Conclusion: Laparoscopic varicocelectomy is efficient, less time-consuming, with minimal postoperative complications. It can be performed easily in the outpatient department.

The Evaluation of the Effect of TENS Therapy on Reducing Acute and Chronic Pain Following Varicocelectomy

Introduction: Post-varicocelectomy pain is a considerable pain with probability of promotion toward chronicity. Some reasons, including surgical technique or nerve injury and inappropriate attention to treatment of acute pain play role in the emergence of acute pain. The pain could lead to limitation in movement and working, patient dissatisfaction and waste of medical resources. Transcutaneous electrical nerve stimulation (TENS) therapy as the patient control analgesia (PCA) is associated with reduction of pain intensity and analgesic consumptions. This study aimed to evaluate the effect of TENS therapy on reducing the acute and chronic pain following varicocelectomy. Methods and Materials: The study was conducted after obtaining the approval of the local Institute Ethics Committee and written informed consent from all of the patients. Eighty patients scheduled for undergoing varicocelectomy, were randomly classified according to a randomization list prepared using online software at a 1:1 ratio to Groups A (intervention group) and B (placebo group). In postoperative and recovery period, Group A received TENS therapy for 30 minutes in parallel to surgical scar with high frequency by sensory level. Group B was treated with off-device. The treatment course was replicated for the two groups at 2, 6, 12 and 24 hours after operation. Then, postoperative pain was measured by VAS (visual analogue scale) at the same time and after 1 week and 1, 2 and 3 months. The amount of used analgesics was recorded. Results: The results showed that based on the VAS, pain significantly decreased after intervention in 2 hours (25% with VAS = 5 versus 32.5% with VAS = 8 in control group). The differences among, amount of used analgesics at 2, 6 and 12 hours were significant with p-value = 0.001, <0.0001 and =0.02, respectively. Conclusion: TENS therapy could efficiently decrease pain degree for hours, weeks and months after varicocelectomy;this was associated with decreased post-operation analgesic requirements.

Predictors of microsurgical varicocelectomy efficacy in male infertility treatment:critical assessment and systematization

In this review,we tried to systematize all the evidence(from PubMed[MEDLINE],Scopus,Cochrane Library,EBSCO,Embase,and Google Scholar)from 1993 to 2021 on the predictors of microsurgical varicocelectomy efficacy in male infertility treatment.Regarding the outcomes of varicocele repair,we considered semen improvement and pregnancy and analyzed them separately.Based on the 2011 Oxford CEBM Levels of Evidence,we assigned a score to each trial that studied the role of the predictor.We systematized the studied predictors based on the total points,which were,in turn,calculated based on the number and quality of studies that confirmed or rejected the studied predictor as significant,into three levels of significance:predictors of high,moderate,and low clinical significance.Preoperative total motile sperm count(TMSC)coupled with sperm concentration can be a significant predictor of semen improvement and pregnancy after varicocelectomy.In addition,for semen improvement alone,scrotal Doppler ultrasound(DUS)parameters,sperm DNA fragmentation index(DFI),and bilateral varicocelectomy are reliable predictors of microsurgical varicocelectomy efficacy.

Comparison of surgical effect and postoperative patient experience between laparoendoscopic single-site and conventional laparoscopic varicocelectomy, a systematic.review and meta-analysis

The present meta-analysis was conducted to compare the clinical effect and patient experience of laparoendoscopic single-site varicocelectomy （LESSV） and conventional laparoscopic varicocelectomy. The candidate studies were included after literature search of database Cochrane Library, PubMed, EMBASE, and MEDLINE. Related information on essential data and outcome measures was extracted from the eligible studies by two independent authors, and a meta-analysis was conducted using STATA 12.0 software. Subgroup analyses were conducted by study design （RCT and non-RCT）. The odds ratio （OR） or standardized mean difference （SMD） and their 95% confidence intervals （95% CIs） were used to estimate the outcome measures. Seven articles were included in our meta-analysis. The results indicated that patient who had undergone LESSV had a shorter duration of back to work （overall： SMD = -1.454, 95% Ch -2.502m0.405, P= 0.007; non-RCT： SMD = -2.906, 95% Ch -3.796-2.017, P= 0.000; and RCT： SMD = -0.841, 95% Ch -1.393-0.289, P = 0.003） and less pain experience at 3 h or 6 h （SMD = -0.447, 95% Ch -0.754-0.139, P = 0.004）, day 1 （SMD = -0.477, 95% Ch -0.905-0.05, P = 0.029）, and day 2 （SMD = -0.612, 95% Ch -1.099-0.125, P= 0.014） postoperatively based on RCT studies. However, the meta-analyses based on operation time, clinical effect （improvement of semen quality and scrotal pain relief）, and complications （hydrocele and recurrence） yielded nonsignificant results. In conclusion, LESSV had a rapid recovery and less pain experience over conventional laparoscopic varicocelectomy. However, there was no statistically significant difference between the two varicocelectomy techniques in terms of the clinical effect and the incidence of hydrocele and varicocele recurrence. More high-quality studies are warranted for a comprehensive conclusion.

A retrospective review of single-institution outcomes with robotic-assisted microsurgical varicocelectomy

We report the largest single-center experience with robotic-assisted microscopic varicocelectomy （RAMV） in male infertility. From August 2012 to February 2015, men with infertility of at least a year and varicoceles underwent RAMV by a single surgeon. Varicocele was diagnosed on physical examination and confirmed by ultrasound by a single ultrasonographer. Preoperative hormone panel, semen analyses, and testicular Doppler ultrasound were obtained from all men and repeated at 3 months. One hundred and forty consecutive men （258 varicocelectomies） were included. Mean age and duration of infertility was 36.4 and 2.8 years, respectively. Median total and free testosterone increased by 145 ng dl^-1 and 4.3 pcg ml^-1 （44.3%）, respectively （P 〈 0.0001）. Median sperm concentration increased by 37.3% （P 〈 0.03）. Median sperm motility and morphology did not significantly change. Median left and right testicular volume increased by 22.3% （P 〈 0.0001） and 12.6% （P 〈 0.0006）, respectively. Hydroceles occurred 0.8% of procedures. We had no testicular artery injuries. Persistence of varicocele by Doppler ultrasound was 9.6%. Only 37.3% of patients required pain medications postoperatively. We concluded that RAMV is a safe and effective alternative for varicocele repair with outcomes comparable to historical traditional microsurgical approach.

The application of laparoscopic Doppler ultrasound during laparoscopic varicocelectomy in infertile men

The aim of this study is to evaluate the benefits of laparoscopic Doppler ultrasound （LDU） application during laparoscopic varicocelectomy （LV）, and to compare the surgical outcomes and complications between LDU-assisted LV （LDU-LV） and conventional LV for infertile patients with varicoceles; 147 infertile patients were randomly divided into two groups. Operative and postoperative parameters, semen parameters, and the pregnancy rate were compared. There were no differences in baseline demographics. The operative time was significantly longer in LDU-LV group than LV group. The incidence of postoperative hydrocele was 1.4% （1/72） in LDU-LV group versus 10.7% （8/75） in LV group, which showed a significant difference （P〈 0.05）. However, other surgical outcomes, such as postoperative hospital stay, postoperative recurrence, and testicular atrophy, were similar between the two groups. Sperm concentration and sperm motility were significantly increased in both groups at 3, 6, and 12 months after surgery （P 〈 0.01）, and they were higher in LDU-LV than LV group in 12 months after surgery （34.21 ± 6.36 vs 29.99 ± 6.04 for concentration, P〈 0.05; 40.72±8.12 vs 37.31 ± 6.12 for motility, P〈 0.05）. Sperm morphology was comparable between the two groups. The pregnancy rate showed no significant difference （44.4% of the LDU-LV vs 37.3% of the LV, P〉 0.05）. In conclusion, compared with LV, LDU-LV could safely and effectively ligate all spermatic veins and preserve spermatic arteries without leading to high varicocele recurrence and postoperative hydrocele. Given the benefits that sperm counts as well as sperm motility favoring LDU-LV, we recommend that LDU should be routinely used as an effective tool to improve outcomes and safety of laparoscopic varicocelectomy.

Computer-aided sperm analysis： a useful tool to evaluate patient＇s response to varicocelectomy

Preoperative and postoperative sperm parameter values from infertile men with varicocele were analyzed by computer-aided sperm analysis （CASA） to assess if sperm characteristics improved after varicocelectomy. Semen samples of men with proven fertility （n = 38） and men with varicocele-related infertility （n = 61） were also analyzed. Conventional semen analysis was performed according to WHO （2010） criteria and a CASA system was employed to assess kinetic parameters and sperm concentration. Seminal parameters values in the fertile group were very far above from those of the patients, either before or after surgery. No significant improvement in the percentage normal sperm morphology （P = 0. 10）, sperm concentration （P = 0.52）, total sperm count （P = 0.76）, subjective motility （%） （P = 0.97） nor kinematics （P = 0.30） was observed after varicocelectomy when all groups were compared. Neither was significant improvement found in percentage normal sperm morphology （P = 0.91）, sperm concentration （P =0. 10）, total sperm count （P = 0.89） or percentage motility （P = 0.77） after varicocelectomy in paired comparisons of preoperative and postoperative data. Analysis of paired samples revealed that the total sperm count （P = 0.01） and most sperm kinetic parameters： curvilinear velocity （P = 0.002）, straight-line velocity （P = 0.0004）, average path velocity （P = 0.0005）, linearity （P = 0.02）, and wobble （P = 0.006） improved after surgery. CASA offers the potential for accurate quantitative assessment of each patient＇s response to varicocelectomy.

Varicocele: How this condition and its management affects men's health

Varicocele is a relatively common condition that can impact men’s health in various ways.Unfortunately,its prevalence and the availability of various different methods of repairing it might lead to unnecessary treatment.An understanding of the various ways that this condition can impact men’s health is necessary in order to manage it appropriately.At present,there is substantial evidence to support varicocele repair in men who present with infertility,abnormal semen parameters,clinical varicocele and a female partner with normal fertility(or one with a potentially correctable abnormality).Varicocele repair appears to improve seminal fluid quality and might improve pregnancy rates.It might also have a role in managing men with non-obstructive azoospermia.Varicocele can also be a cause of scrotal pain that is usually of a dull character.Varicocele repair is an effective method of managing this type of pain,especially once proper measures have been taken to exclude other possible causes of orchalgia.Conservative measures are generally not effective in managing varicocele-related scrotal pain.There is growing evidence to suggest that varicocele repair might have a role in improving the serum testosterone level in men with hypogonadism,especially in the subfertile population.Well-designed prospective studies are needed to support the utilization of varicocele repair inmanaging these patients,as well as in preventing testicular dysfunction on a prophylactic basis.

The evolution and refinements of varicocele surgery

Varicoceles had been recognized in clinical practice for over a century. Originally, these procedures were utilized for the management of pain but, since 1952, the repairs had been mostly for the treatment of male infertility. However, the diagnosis and treatment of varicoceles were controversial, because the pathophysiology was not clear, the entry criteria of the studies varied among centers, and there were few randomized clinical trials. Nevertheless, clinicians continued developing techniques for the correction of varicoceles, basic scientists continued investigations on the pathophysiology of varicoceles, and new outcome data from prospective randomized trials have appeared in the world＇s literature. Therefore, this special edition of the Asian Journal of Andrology was proposed to report much of the new information related to varicoceles and, as a specific part of this project, the present article was developed as a comprehensive review of the evolution and refinements of the corrective procedures.

Novel insights into the pathophysiology of varicocele and its association with reactive oxygen species and sperm DNA fragmentation

Varicocele has been associated with reduced male reproductive potential. With the advances in biomolecular techniques, it has been possible to better understand the mechanisms involved in testicular damage provoked by varicocele. Current evidence suggests the central role of reactive oxygen species （ROS） and the resultant oxidative stress （OS） in the pathogenesis of varicocele-associated male subfertility although the mechanisms have not yet been fully described and it is likely to be multifactorial. Excessive ROS is associated with sperm DNA fragmentation, which may mediate the clinical manifestation of poor sperm function and fertilization outcome related to varicocele. Testing of ROS/OS and DNA fragmentation has the potential to provide additional diagnostic and prognostic information compared to conventional semen analysis and may guide therapeutic management strategies in individual patient.

Outcome of varicocele repair in men with nonobstructive azoospermia： systematic review and meta-analysis

The objective of this systemic review was to evaluate the benefit of repairing clinical varicocele in infertile men with nonobstructive azoospermia （NOA）. The surgically obtained sperm retrieval rate （SRR） and pregnancy rates following assisted reproductive technology （ART） with the use of retrieved testicular sperm were the primary outcomes. The secondary outcomes included the presence of viable sperm in postoperative ejaculate to avoid the testicular sperm retrieval and pregnancy rates （both assisted and unassisted） using postoperative ejaculated sperm. An electronic search to collect the data was performed using the MEDLINE and EMBASE databases until April 2015. Eighteen studies were included in this systematic review and accounted for 468 patients who were diagnosed with NOA and varicocele. These patients were subjected to either surgical varicocele repair or percutaneous embolization. Three controlled studies evaluating sperm retrieval outcomes indicated that in patients who underwent varicocelectomy, SRR increased compared to those without varicocele repair （OR： 2,65; 95% Cl. 1.69-4.14; P 〈 0.001）. Although pregnancy rates with the use of testicular sperm favored the varicocelectomy group, results were not statistically significant （clinical pregnancy rate OR： 2.07; 95% CI： 0.92-4.65; P = 0.08; live birth rate OR： 2.19; 95% CI： 0.99-4.83; P = 0.05）. The remaining fifteen studies reported postoperative semen analysis results. In 43.9% of the patients （range： 20.8%-55.0%）, sperm were found in postoperative ejaculates. Pregnancy rates for unassisted and assisted （after IVF/ICSI） were 13.6% and 18.9% in the group of men with sperm in postoperative ejaculates, respectively. Our findings indicate that varicocelectomy in patients with NOA and clinical varicocele is associated with improved SRR. In addition, approximately 44% of the treated men will have enough sperm in the ejaculate to avoid sperm retrieval. Limited data on pregnancy outcomes with both postoperative ejaculated sperm and harvested testicular sperm preclude any firm conclusion with regard to the possible increased fertility potential in treated individuals. In conclusion, the results of our study indicate that infertile men with NOA and clinical varicocele benefit from varicocelectomy. Given the low/moderate quality of evidence available, it is advisable that doctors discuss with their patients with NOA the risks and benefits of varicocele repair.

Outcome of assisted reproductive technology in met with treated and untreated varicocele, systematic review and meta-analysis

Varicocele affects approximately 35%-40% of men presenting for an infertility evaluation. There is fair evidence indicating that surgical repair of clinical varicocele improves semen parameters, decreases seminal oxidative stress and sperm DNA fragmentation, and increases the chances of natural conception. However, it is unclear whether performing varicocelectomy in men with clinical varicocele prior to assisted reproductive technology （ART） improve treatment outcomes. The objective of this study was to evaluate the role of varicocelectomy on ART pregnancy outcomes in nonazoospermic infertile men with clinical varicocele. An electronic search was performed to collect all evidence that fitted our eligibility criteria using the MEDLINE and EMBASE databases until April 2015. Four retrospective studies were included, all of which involved intracytoplasmic sperm injection （ICSI）, and accounted for 870 cycles （438 subjected to ICSI with prior varicocelectomy, and 432 without prior varicocelectomy）. There was a significant increase in the clinical pregnancy rates （OR = 1.59, 95% CI. 1.19-2.12, 12 = 25%） and live birth rates （OR = 2.17, 95% CI： 1,55-3.06, I^2 = 0%） in the varicocelectomy group compared to the group subjected to ICSI without previous varicocelectomy. Our results indicate that performing varicocelectomy in patients with clinical varicocele prior to ICSI is associated with improved pregnancy outcomes.

Summary evidence on the effects of varicocele treatment to improve natural fertility in subfertile men

The objective of this review was to summarize the evidence concerning the benefit of varicocele treatment to improve natural fertility in subfertile males. We also analyzed the effect of varicocele treatment on conventional semen parameters and sperm functional tests. An electronic search to collect the data was performed using the PubMed/MEDLINE databases until July 2015. Data pooled from a variety of study designs indicate that varicocelectomy improves semen parameters in the majority of the treated men with clinical varicocele and abnormal semen parameters regardless of the chosen surgical method. Surgical varicocele repair was beneficial not only for alleviating oxidative stress-associated infertility but also to improve sperm nuclear DNA integrity. However, given the low magnitude of the effect size in sperm DNA integrity, further research is needed to elucidate its clinical significance. Conflicting results on the effect of varicocele treatment on natural fertility seem to be due to heterogeneous study designs and, more importantly, patient selection criteria. When these issues are controlled, current evidence indicates that treatment of subclinical varicocele is not warranted, as it does not seem to improve fertility. On the contrary, fair evidence indicates that varicocele treatment should be offered to infertile patients with palpable varicocele and abnormal semen parameters. This evidence supports the current guidelines issued by the American Urological Association and European Association of Urology, which state that varicocele treatment should be offered to male partners of infertile couples presenting for evaluation with clinical varicocele and semen parameters alterations.