Varicocele repair: bringing couples in to the decision
Shared decision making by both physicians and infertile couples, may be the way forward in tackling the complex issue of varicocele management.
It is a longstanding debate as to what is the most appropriate approach in the management of varicocele in the infertile couple. Although many studies have addressed the issue and, while Medical Societies, such as the ASRM, the AUA and the EUA have produced guidelines, varicocele management remains a matter of debate in many instances.
So it was with interest to listen to Jesse Mills, MD, address on the subject, during the 2021 Annual Meeting of ASRM in Baltimore, this past October. The concept of shared decision making involves not only physicians getting to counsel infertile couples diagnosed with varicocele among other infertility-related conditions, it encourages couples to take an active part in future steps and treatment planning.
Undoubtedly, it all begins by providing adequate information about the nature of varicocele, the mechanisms by which it may impair testicular function, while exploring the different scenarios in which a varicocele may be encountered. While the evidence is in favour of varicocele repair in clinically symptomatic cases with proven oligoasthenospermia, in other clinical cases it remains unclear whether it improves outcomes, such as IVF/ICSI treatment, azoospermia and subclinical varicocele.
Identifying the negative impact that a varicocele has on sperm function it may help infertile couples with male factor infertility to consider having a varicocele repair, provided female age is not a contraindication, or that other medical conditions do not make ART treatment obligatory, as with tubal pathology.
So far the evidence has not clearly shown a benefit to all men having a varicocele repair with regards to pregnancy achievement, outside the setting of symptomatic varicocele with sperm impairment. However, in selected cases a varicocele repair could be offered in ICSI cases where fertilisation and embryological development did not go well in a previous ICSI cycle.
Likewise, before embarking on ICSI treatment, provided no other contraindications exist, a couple with male factor infertility may want to explore the possibility of having a varicocele repair and thus moving closer to achieving a pregnancy through IUI.
Last, studies have suggested that varicocele repair has benefited some men with azoospermia in restoring spermatogenesis and subsequently leading to spontaneous pregnancies, specifically in cases where histology of testicular tissue suggests hypospermatogenesis or late maturation arrest.
As infertile couples face a decisional conflict as to how to proceed to the next step in infertility treatment, given that the evidence is neither so strong, nor so abundant, it is important that infertility specialists explain in a clear manner the current status of knowledge and encourage couples to participate in decision making, especially, when such multifactorial conditions are present, as in infertility management.
©2021, Nicholas Christoforidis, Fertility Matters
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