Abstract
Study question
Does microsurgical subinguinal varicocelectomy (MSV) improve semen parameters and fertility outcomes of patients with severe oligozoospermia (SO) and clinical varicocele?
Summary answer
MSV significantly improves semen parameters of patients with SO and can broaden their fertility treatment options. What is known already: Varicocele ligation has been proven to restore semen parameters and improve pregnancy rates in men with clinically palpable disease. However, its effect in men with SO is less clearly elucidated. Patients with SO are candidates for in vitro fertilization and intracytoplasmic sperm injection. Improvements in semen quality following varicocele ligation in this patient population may broaden their fertility options. While few studies indicate an improvement in semen parameters, reports revealing a negative outcome following surgery in this patient group were also published.
Study design, size, duration
This original report and meta-analysis examined the impact of MSV on semen parameters and fertility outcomes of men with SO. A retrospective chart review of 85 patients was conducted on patients with SO who underwent MSV. A literature search was carried out according to the PRISMA guidelines using the key words “severe oligozoospermia” and “varicocele”. 8 scientific articles (including the current study) reporting the impact of MSV on men with SO were included.
Participants/materials, setting, methods
Changes in semen parameters postoperatively were compared with pre-operative results. The reported natural pregnancy rates were also calculated. The Wilcoxon signed-rank test was used to compare semen and hormone values before and after varicocelectomy. The Chi-squared test was used to assess the changes in TMSC groups after surgery. The meta-analysis was performed using comprehensive meta-analysis software (Biostat, Englewood, NJ, USA). Statistical significance was set at α = 0.05. The random-effects model was used to adjust for heterogeneity.
Main results and the role of chance
The original study reported significant improvements in sperm concentration (p < 0.001), total motility (p = 0.003), progressive motility (p = 0.002) and TMSC (p < 0.001) was following the surgery. in semen parameters following surgery. 78 patients had a pre-operative TMSC < 5 million. Following surgery, 9 (11.5%) patients had a TMSC between 5–9 million, while 14 (17.9%) patients had a TMSC > 9 million. The meta-analysis shows a statistically significant increase in sperm count following surgery (MD 5.64, 95% CI, 4.195–7.090, p = 0.00) with an acceptable degree of heterogeneity (Q value= 8.75, p = 0.188, I²= 31.5%). Similarly, the total motility significantly increased by 7.77% (p = 0.001) following surgery (95% CI, 3.248–12.297), however, with considerable heterogeneity among the reported results (Q value= 34.4, p < 0.001). TMSC was assessed by three studies, including ours. The meta-analysis shows a significant increase in TMSC following surgery (MD 8.44 million sperm, 95% CI, 4.648–12.228, p < 0.001) (Q Value= 2.53, p = 283, I²=20.7%).
A total of 6 studies reported the natural pregnancy rate of patients with SO who underwent surgery. Out of 530 patients with preoperative SO, 146 patients achieved natural pregnancy following surgery indicating that the reported pregnancy rate was 27.5%.
Limitations, reasons for caution
One limitation to the original study is its relatively small sample size. However, this was compensated by conducting a meta-analysis and reporting the outcome of 601 patients with SO who underwent varicocele ligation. Another limitation is the retrospective nature of the study design.
Wider implications of the findings: 29.5% of SO patients in the original study became eligible for IUI following varicocelectomy. Meta-analysis showed that 27.5% of patients achieved natural conception following surgery. Such information is beneficial during patient counselling and needs to be measured against the financial and clinical implications in order to make sound treatment decisions.
Trial registration number
NA
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