Varicocoele repair: the role of the duration of infertility.

Giagulli & Carbone (2011) have investigated in a comparative study which factors determine the success of varicocoele repair. They concluded that the duration of the infertility makes a difference in the number of spontaneous pregnancies: couples with an infertility duration of more than 2 years showed a significantly higher pregnancy rate compared with couples with an uncorrected varicocoele. For couples with a shorter duration of infertility, such a difference was not observed. Although this is not a randomized controlled trial (RCT), it is remarkable that a benefit in terms of more spontaneous pregnancy was only present after 2 years of infertility. This seems to be of importance for proper selection of candidates for treatment. The role of varicocoele repair in improving male infertility has not been shown in a large RCT. In fact, most of the published RCTs on varicocoele treatment for male infertility show no benefit in terms of higher pregnancy rates in the treated couples (Evers & Collins, 2009). Although sperm improvement is usually observed after varicocoele repair, it seems difficult to show that treatment also improves fertility outcome (Argawal et al., 2007). The reason for this remains unclear, but several factors may be responsible for the absence of a clear difference between treated couples and controls. First of all, it may be true that varicocoele is not effective in improving the fertility status of a couple. This, however, seems to be in contrast to the improvement of semen quality and DNA fragmentation of spermatozoa as observed after surgical varicocoele repair (Argawal et al., 2007; Smit et al., 2010). Secondly, the size of the varicocoele may be important: in three small RCTs, treatment of subclinical varicocoeles appeared as good as no treatment (Yamamoto et al., 1996; Grasso et al., 2000; Unal et al., 2001). Treatment of subclinical varicocoele cannot be recommended. Preoperative sperm quality seems to be a third important factor for the outcome of varicocoele repair: two RCTs with mainly normospermic men and a varicocoele showed no benefit in the number of pregnancies as compared with controls (Nilsson et al., 1979; Breznik et al., 1993). In fact, varicocoeles are frequently observed in men with normal semen analysis, and routine treatment of all varicocoeles would be overtreatment if the fertility status of the patient and his partner is not considered (Zargooshi, 2007). Also, in men with non-obstructive azoospermia and severe oligozoospermia, the benefit of an operation in terms of spontaneous pregnancies appeared very limited and assisted reproduction is still needed (Schlegel & Kaufmann, 2004; Ishikawa et al., 2008). In many infertile couples, female factors, such as ovulatory disorders, coincide with the presence of the varicocoele, and successful correction of these factors could also account for the increase in spontaneous pregnancies, both in the couples treated for varicocoele as in the control group (Baker et al., 1985; Nieschlag et al., 1998). It remains to be proven that varicocoele repair is beneficial for infertile couples, especially in men with a clinical varicocoele, oligozoospermia and otherwise unexplained infertility (Evers & Collins, 2009). Giagulli & Carbone (2011) have added a fourth criterion to the subgroup of patients who might benefit from varicocoele treatment: an infertility duration of at least 2 years. In couples with unexplained infertility, the chance of spontaneous pregnancy after 1 year of infertility is as high as 49% for the next year, and still an annual 20% in couples with 2 years of infertility (Te Velde et al., 2000). Only after 3 years, the pregnancy rates drop to 14%. This seems different for couples with a varicocoele: Baker et al. (1985) showed that in a group of 651 untreated men with a clinical varicocoele, spontaneous pregnancy was 30% in the second year of infertility and 15% in the third year. If we compare this with the figures of couples with unexplained infertility, it may be concluded that varicocoele negatively influences natural conception rate. Abnormal semen analyses also seem relevant to the chance of natural conception: in a group of untreated oligozoospermic men from infertile couples, the cumulative life birth rate after 36 months of observation was 32% compared with 60% in couples with unexplained infertility and normal sperm counts (Snick et al., 1997). This indicates that both the duration of infertility and the results of semen analysis need to be considered before varicocoele repair is performed for the treatment of male infertility. Varicocoele repair results in spontaneous pregnancy in about 25–30% of couples within 1 year of observation after treatment (Dubin & Amelar, 1977; Nieschlag et al., 1998). It therefore seems logical to postpone treatment in couples who still have a similar annual chance of spontaneous pregnancies: this can be calculated using the prediction of spontaneous pregnancy model of Hunault et al. (2004). In general, any treatment of infertile couples should not start before 2 years of unprotected regular intercourse, unless there are abnormalities found that international journal of andrology ISSN 0105-6263