Youth varicocele and varicocele treatment A meta analysis of semen outcomes

Capsule:
A meta-analysis of the literature regarding youth varicocele and semen outcomes demonstrates an overall negative effect of varicocele on semen, and improvement of semen parameters following varicocele treatment.

Authors:
Justin J. Nork, D.O., Jonathan H. Berger, M.D., Donald S. Crain, M.D., Matthew S. Christman, M.D.

Volume 102, Issue 2, Pages 381–387.e6

Abstract:

Objective:
To study youth who have a varicocele or are undergoing varicocele treatment, in relation to changes in semen, as measured by semen analysis (SA).

Design:
Meta-analysis of studies identified via a search of PubMed, Medline, and the Cochrane Library covering the last 40 years.

Setting:
Not applicable.

Patient(s):
Youth from studies that assessed the presence and/or treatment of varicocele with SA.

Intervention(s):
Selected studies were analyzed in two separate meta-analyses: one for the effect of varicocele on semen, as measured by SA (hypothesis #1), the other for the effect of treatment on semen, as measured by SA (hypothesis #2).

Main Outcome Measure(s):
A random-effects model was used to calculate weighted mean difference (WMD) of semen outcomes. Heterogeneity was calculated. Bias was assessed with funnel plots and Egger’s test.

Result(s):
The initial literature search returned 1,180 potentially relevant articles. For hypothesis #1, 10 studies with a total of 357 varicocele and 427 control subjects were included. Sperm density, motility, and morphology were significantly decreased when associated with a varicocele, with a WMD of −24.0 × 106/mL (95% confidence interval [CI; −39.5 to −8.6]), −7.5% (95% CI [−12.3% to −2.7%]), and −1.7% (95% CI [−2.4% to −1.1%]), respectively. Another 10 studies with 379 treated and 270 untreated subjects were analyzed for hypothesis #2. Sperm density and motility were significantly improved following treatment, with a WMD of 14.6 × 106/mL (95% CI [7.1–22.1]) and 6.6% (95% CI [2.1%–11.2%]), respectively.

Conclusion(s):
The presence of varicocele in youth appears to negatively affect sperm density, motility, and morphology. Treatment appears to result in moderate improvement of sperm density and mild improvement in sperm motility.

  • Jason Kovac

    I agree with Edmund.
    I think this study raises more questions than anything. Wouldn’t this actually be treating a semen analysis rather than treating anything at all? There are many men who have varicoceles with slightly abnormal semen analysis who we would not operate on so why do we expose children to a surgery simply to fix a lab value?
    Furthermore, this study is an example of what some could use as an argument for repairing pediatric varicoceles – to improve semen parameters that may not even be an issue. Exposing a “youth” to un-necessary procedures is difficult to understand.
    The key here would be to follow these same children and see what the fertility outcomes are. Is there any difference at all with respect to the pregnancy rates? I’m willing to bet probably not.

  • Interesting meta-analysis on effects of adolescent varicocele pre and post repair. Large cohort single institution prospective randomized controlled studies have not been performed due to the logistic difficulties in obtaining semen analyses from this age group. The findings of this pooled review suggest that adolescents with varicoceles exhibit similar stress patterns in their SA as adults. Repair also improves SA findings. Due to these findings, the authors suggest that this may be another indication for repairing varicoceles in this age group. I applaud the authors in performing this extensive meta-analysis and exhaustive review.

    Several questions that should be considered:
    1. What are the size of varicoceles?
    2. Unilateral vs bilateral varicoceles?
    3. What is the natural progression of the effect of varicocele on semen analysis parameters over time?
    4. How does an abnormal adolescent semen analysis affect future adult fertility potential?
    5. Can serum or seminal proteomics be utilized to predict fertility potential and identify which adolescent varicoceles should be repaired to protect future fertility?

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