Surgery or embolisation for varicoceles in subfertile men.
BACKGROUND
A varicoceles is a meshwork of distended blood vessels in the scrotum, usually left-sided, due to dilatation of the spermatic vein. Although the concept that varicoceles causes, and varicocelectomy cures, male subfertility has been around for almost fifty years, the mechanisms by which varicoceles would affect fertility have not yet been satisfactorily explained, and neither have the mechanisms by which varicocelectomy would restore fertility. Furthermore, it has been questioned whether a causal relation exists at all between the distension of the pampiniform plexus and impairment of fertility.


OBJECTIVE
To evaluate the effect of varicoceles treatment on pregnancy rate in subfertile couples.


METHODS
We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (12 Sept 2003 and October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004 and Issue 4, 2007), MEDLINE (January 1966 to October 2007), EMBASE (January 1985 to October 2007) and reference lists of articles. In addition, we handsearched specialist journals in the field from their first issue until 2007. We also checked cross-references, references from review articles and contacted researchers in the field.


METHODS
Randomised controlled trials (RCTs) were included if they were relevant to the clinical question posed, if they reported pregnancy rates as an outcome measure, and if they reported data in treated (surgical ligation or radiological embolisation of the internal spermatic vein) and untreated groups.


METHODS
Nine studies met the inclusion criteria for the original review. One was an extension of a previously published study, which left eight studies for analysis. All eight only included men from couples with subfertility problems; one excluded men with sperm counts less than 5 million per mL and one men with sperm counts less than 2 million per mL, with or without progressive motility of less than 10%. Two trials involving clinical varicoceles included some men with normal semen analysis. Three studies specifically addressed only men with subclinical varicoceles. Two authors independently screened potentially relevant trials. Any differences of opinion were resolved by consensus (none occurred for this review). Studies were excluded from meta-analysis if they made comparisons other than those specified above.


RESULTS
The combined Peto odds ratio (OR) of the eight studies is 1.10 (95%CI 0.73 to 1.68), indicating no benefit of varicoceles treatment over expectant management in subfertile couples in whom varicoceles in the man is the only abnormal finding.


CONCLUSIONS
There is no evidence that treatment of varicoceles in men from couples with otherwise unexplained subfertility improves the couple's chance of conception.
Evers
Johannes Hans L H
JH
Department of Obstetrics & Gynaecology, Academisch Ziekenhuis Maastricht, PO Box 5800, Maastricht, Netherlands, 6202 AZ. jev@sgyn.azm.nl
Collins
John
J
Clarke
Jane
J
D004621:Embolization, Therapeutic; D005260:Female; D006801:Humans; D007248:Infertility, Male / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D008297:Male; D017063:Outcome Assessment, Health Care; D011247:Pregnancy; D018873:Pregnancy Rate; D016032:Randomized Controlled Trials as Topic; D014646:Varicocele / Q000150:complications / Q000601:surgery / Q000628:therapy*