Male Infertility and Varicocele: An Update

Varicocele is the dilatation of the pampiniform plexuses. It is a treatable cause of infertility. The incidence is higher in infertile men, ranging from 35-80%. Although various mechanisms are postulated for the formation of varicocele, the pathological mechanisms by which varicocele causes sperm dysfunction are oxidative stress, testicular hypoperfusion, and heat stress. Various studies have documented venular and testicular architectural changes secondary to varicocele. Varicocele repair in the management of male infertility had been controversial. Recent randomized controlled trials have shown that many of these factors are reversible following varicocele repair and it results in a definitive improvement in sperm DNA fragmentation and semen parameters. Several meta-analyses and RCTs have shown that following varicocele repair, there is a statically significant improvement in both pregnancy rates and live birth rates. Even in the era of assisted reproductive technology, varicocele repair helps to resort to lesser invasive techniques with better pregnancy rates and live birth rates. The outcome of assisted reproductive technology also improves following varicocele repair. This also results in cost-effectiveness in achieving pregnancy. There are many techniques for varicocele repair. A meta-analysis of randomized controlled trials has been done to identify the best technique in terms of semen parameter improvement and post-operative recovery. Most techniques result in similar improvement of semen parameters, but the complication rate is the least with micro- sub inguinal varicocelectomy. The use of intraoperative doppler also helps in the identification of all branches of the testicular artery.