P-040 Impact of varicocele on male fertility potential: comparison of unilateral vs bilateral disease on clinical presentation and outcome of varicocelectomy
Authors: Majzoub A , Arafa M , Khalafalla K , Alsaid S , Elbardisi H 
Published: June 2022

Abstract

Study question
Is there a difference between unilateral and bilateral varicocele on clinical presentation and postsurgical outcome of infertile men undergoing microsurgical subinguinal varicocelectomy?

Summary answer
Patients with bilateral varicocele have significantly worse clinical presentation than unilateral disease. Significantly greater improvement in total motility was detected with bilateral varicocele ligation.

What is known already
Varicocele is a common clinical condition with significant implications on male fertility potential. In the majority of cases, varicocele is unilateral affecting the left spermatic veins. Nonetheless a minority of patients may present with bilateral clinical disease. It is not entirely clear whether patients with bilateral clinical varicocele can have a more significant deterioration in testicular function than unilateral varicocele patients. Furthermore, a clear comparison of the outcome of varicocele ligation between patients with bilateral and unilateral clinical disease has not been clearly elucidated.

Study design, size, duration
This retrospective chart review was conducted at a tertiary medical center and included the charts of 1170 age matched patients who underwent microsurgical subinguinal varicocelectomy over an 8 year-period. Patients were classified into 2 groups; group 1 (n = 977; those who underwent unilateral varicocelectomy) and group 2 (n = 193; those who underwent bilateral varicocelectomy). Patients with genetic abnormalities, history of orchitis or chemoradiation were excluded.

Participants/materials, setting, methods
Patients’ demographics, varicocele grade and laterality, semen results, sperm DNA fragmentation and hormones levels initially and 3 months following varicocele ligation were collected. Frequency, median(IQR) or mean±SD were used to report categorical and numerical values, respectively. Mann-Whitney test and Repeated measures analysis of variance were used for statistical analysis of data. A p value &lt; 0.05 was considered significant.

Main results and the role of chance
The patients’ mean age and body mass index were 34.5 ± 8.2 years and 28.13 ± 5.8 Kg/m2, respectively. Left varicocele was of grade 1 in 3.5% of cases, grade 2 in 52.8% and grade 3 in 43.7% with a mean diameter of 3.9 ±0.9mm. Right varicocele was of grade 1 in 59.6% of cases, grade 2 in 31.6% and grade 3 in 8.8% with a mean diameter of 2.5 ± 0.9mm. Preoperatively, patients with bilateral varicocele had significantly lower total motility (38 [17, 53.5] % vs 45 [20, 59] %, p = 0.027) and progressive motility (6 [0, 19.7] % vs 10 [0, 25] %, p = 0.039) and significantly higher serum FSH levels (4 [2, 6.1] IU/L vs 3.2 [2, 5.4] IU/L, p = 0.042) than patients with unilateral varicocele. Following varicocele ligation, significant improvements were noted in sperm concentration, total motility and progressive motility in both groups (group 1: p &lt; 0.001 for all; group 2: p = 0.007, 0.003 and 0.003 respectively). Between group comparisons reveal a significantly greater increase in only total motility following surgery in the bilateral varicocele group compared with the unilateral group (median difference +9 [-5, +18] % vs + 5 [-5, +17] %, p = 0.045).

Limitations, reasons for caution
The retrospective nature of the study is one limitation. Discrepancies in the sample size between the two groups is another limitation though this is affected by the low prevalence of right varicocele.

Wider implications of the findings
Bilateral clinical varicocele is more detrimental on testicular function than unilateral disease. Proper identification and concomitant treatment of right varicocele may result in a better improvement in male fertility potential.

Trial registration number
Not applicable