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The report from the 2023 annual conference of French Urology Association (AFU), which was dedicated to male fertility, focused heavily on the diagnosis and treatment of varicocele, the most common reversible cause of infertility in men. Long a controversial subject, it has now been determined that treating this condition improves sperm analysis results, spontaneous fertility, and outcomes from medically assisted reproduction techniques. The AFU’s conference was a chance to present an overall snapshot of the issue.
Between 1973 and 2018, male sperm concentration dropped by 51.6% around the world, whereas total sperm counts dropped by 62.3%, according to Charlotte Methorst, MD, urological surgeon in Saint Cloud, France, president of the French Language Andrology Society, and coordinator of the AFU 2023 Report on Male Fertility. What’s more,
Declining Fertility
Nowadays, around 15% of couples experience infertility (60,000 new cases/year in France). About 20% of these are strictly attributed to male infertility and 40% are mixed, implying a male factor. Consequently, Dr. Methorst explained that “we must routinely assess male fertility within the context of a medically assisted reproduction (MAR) pathway, without limiting testing to semen analysis. Varicocele, one of the causes of infertility that men should be screened for and defined as an abnormal and/or tortuous enlargement of the pampiniform plexus veins, is present in 15%-20% of the overall male population, 35% of men with primary infertility, and more than 70% of those experiencing secondary infertility.”
In infertile men, varicocele is mostly unilateral, occurring on the left side (85%-90% of cases). A link has been established between varicocele and insufficiency at the saphenofemoral junction, as well as venous insufficiency of the lower limbs (odds ratio, 2.34; P < .0001), suggesting a predisposition towards a vascular network favoring the presence of varicoceles.
Varicocele Underdiagnosed
Analysis of a large multicenter database recently suggested the underdiagnosis of varicocele in men being assessed for infertility. Diagnosis is primarily based on physical examination, with physicians finding a soft, serpiginous swelling in the upper and posterior part of the affected side of the scrotum. Testicular Doppler ultrasonography provides confirmation of a varicocele, taking into account aspects such as size and reflux duration during the Valsalva maneuver. Generally, this is enough to make a differential diagnosis, but MRI may be considered, especially in cases where a millimeter-sized nodule is also found.
Reversal Improves Fertility
A Cochrane meta-analysis, despite containing significant bias, raised doubts about the efficacy of varicocele treatment. Nevertheless, over the past 10 years, a randomized trial and several meta-analyses have put an end to the controversy, confirming that treatment for varicocele significantly improves natural pregnancy rates.
Microscopic subinguinal varicocelectomy is the gold-standard option for cases of clinical varicocele and for those in which sperm analysis findings are abnormal. This approach is associated with superior efficacy outcomes, such as improvement in sperm analysis results and pregnancy rates while leading to lower rates of recurrence (< 4%) and a favorable outcome in terms of complications. It should be noted that treating subclinical varicocele is not recommended.
Specifically, microscopic subinguinal varicocelectomy improves live birth and pregnancy rates, both naturally and via in vitro fertilization. What’s more, it has a positive impact on sperm count, total and progressive motility, morphology, and DNA fragmentation levels. Overall, this surgery changes the MAR approach used in around one in two cases. The grade and unilateral or bilateral nature of varicocele are important predictive factors of improvement in sperm analysis findings and pregnancy rates associated with this interventional procedure. Treating clinical varicocele (grades 1-3) leads to improved sperm analysis results, observed in 60%-70% of cases. According to a meta-analysis, the mean increase is said to be a concentration of 12 million spermatozoids per milliliter, as well as a mean improvement of 11% in sperm motility.
Notably, embolization can be considered as an alternative to surgery. This minimally invasive X-ray-guided procedure performed by an interventional radiologist attempts to block the dilated testicular vein.
Guidelines for clinical practice in treating varicocele were recently published by the AFU’s Andrology committee.
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.
The report from the 2023 annual conference of French Urology Association (AFU), which was dedicated to male fertility, focused heavily on the diagnosis and treatment of varicocele, the most common reversible cause of infertility in men. Long a controversial subject, it has now been determined that treating this condition improves sperm analysis results, spontaneous fertility, and outcomes from medically assisted reproduction techniques. The AFU’s conference was a chance to present an overall snapshot of the issue.
Between 1973 and 2018, male sperm concentration dropped by 51.6% around the world, whereas total sperm counts dropped by 62.3%, according to Charlotte Methorst, MD, urological surgeon in Saint Cloud, France, president of the French Language Andrology Society, and coordinator of the AFU 2023 Report on Male Fertility. What’s more,
Declining Fertility
Nowadays, around 15% of couples experience infertility (60,000 new cases/year in France). About 20% of these are strictly attributed to male infertility and 40% are mixed, implying a male factor. Consequently, Dr. Methorst explained that “we must routinely assess male fertility within the context of a medically assisted reproduction (MAR) pathway, without limiting testing to semen analysis. Varicocele, one of the causes of infertility that men should be screened for and defined as an abnormal and/or tortuous enlargement of the pampiniform plexus veins, is present in 15%-20% of the overall male population, 35% of men with primary infertility, and more than 70% of those experiencing secondary infertility.”
In infertile men, varicocele is mostly unilateral, occurring on the left side (85%-90% of cases). A link has been established between varicocele and insufficiency at the saphenofemoral junction, as well as venous insufficiency of the lower limbs (odds ratio, 2.34; P < .0001), suggesting a predisposition towards a vascular network favoring the presence of varicoceles.
Varicocele Underdiagnosed
Analysis of a large multicenter database recently suggested the underdiagnosis of varicocele in men being assessed for infertility. Diagnosis is primarily based on physical examination, with physicians finding a soft, serpiginous swelling in the upper and posterior part of the affected side of the scrotum. Testicular Doppler ultrasonography provides confirmation of a varicocele, taking into account aspects such as size and reflux duration during the Valsalva maneuver. Generally, this is enough to make a differential diagnosis, but MRI may be considered, especially in cases where a millimeter-sized nodule is also found.
Reversal Improves Fertility
A Cochrane meta-analysis, despite containing significant bias, raised doubts about the efficacy of varicocele treatment. Nevertheless, over the past 10 years, a randomized trial and several meta-analyses have put an end to the controversy, confirming that treatment for varicocele significantly improves natural pregnancy rates.
Microscopic subinguinal varicocelectomy is the gold-standard option for cases of clinical varicocele and for those in which sperm analysis findings are abnormal. This approach is associated with superior efficacy outcomes, such as improvement in sperm analysis results and pregnancy rates while leading to lower rates of recurrence (< 4%) and a favorable outcome in terms of complications. It should be noted that treating subclinical varicocele is not recommended.
Specifically, microscopic subinguinal varicocelectomy improves live birth and pregnancy rates, both naturally and via in vitro fertilization. What’s more, it has a positive impact on sperm count, total and progressive motility, morphology, and DNA fragmentation levels. Overall, this surgery changes the MAR approach used in around one in two cases. The grade and unilateral or bilateral nature of varicocele are important predictive factors of improvement in sperm analysis findings and pregnancy rates associated with this interventional procedure. Treating clinical varicocele (grades 1-3) leads to improved sperm analysis results, observed in 60%-70% of cases. According to a meta-analysis, the mean increase is said to be a concentration of 12 million spermatozoids per milliliter, as well as a mean improvement of 11% in sperm motility.
Notably, embolization can be considered as an alternative to surgery. This minimally invasive X-ray-guided procedure performed by an interventional radiologist attempts to block the dilated testicular vein.
Guidelines for clinical practice in treating varicocele were recently published by the AFU’s Andrology committee.
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.
The report from the 2023 annual conference of French Urology Association (AFU), which was dedicated to male fertility, focused heavily on the diagnosis and treatment of varicocele, the most common reversible cause of infertility in men. Long a controversial subject, it has now been determined that treating this condition improves sperm analysis results, spontaneous fertility, and outcomes from medically assisted reproduction techniques. The AFU’s conference was a chance to present an overall snapshot of the issue.
Between 1973 and 2018, male sperm concentration dropped by 51.6% around the world, whereas total sperm counts dropped by 62.3%, according to Charlotte Methorst, MD, urological surgeon in Saint Cloud, France, president of the French Language Andrology Society, and coordinator of the AFU 2023 Report on Male Fertility. What’s more,
Declining Fertility
Nowadays, around 15% of couples experience infertility (60,000 new cases/year in France). About 20% of these are strictly attributed to male infertility and 40% are mixed, implying a male factor. Consequently, Dr. Methorst explained that “we must routinely assess male fertility within the context of a medically assisted reproduction (MAR) pathway, without limiting testing to semen analysis. Varicocele, one of the causes of infertility that men should be screened for and defined as an abnormal and/or tortuous enlargement of the pampiniform plexus veins, is present in 15%-20% of the overall male population, 35% of men with primary infertility, and more than 70% of those experiencing secondary infertility.”
In infertile men, varicocele is mostly unilateral, occurring on the left side (85%-90% of cases). A link has been established between varicocele and insufficiency at the saphenofemoral junction, as well as venous insufficiency of the lower limbs (odds ratio, 2.34; P < .0001), suggesting a predisposition towards a vascular network favoring the presence of varicoceles.
Varicocele Underdiagnosed
Analysis of a large multicenter database recently suggested the underdiagnosis of varicocele in men being assessed for infertility. Diagnosis is primarily based on physical examination, with physicians finding a soft, serpiginous swelling in the upper and posterior part of the affected side of the scrotum. Testicular Doppler ultrasonography provides confirmation of a varicocele, taking into account aspects such as size and reflux duration during the Valsalva maneuver. Generally, this is enough to make a differential diagnosis, but MRI may be considered, especially in cases where a millimeter-sized nodule is also found.
Reversal Improves Fertility
A Cochrane meta-analysis, despite containing significant bias, raised doubts about the efficacy of varicocele treatment. Nevertheless, over the past 10 years, a randomized trial and several meta-analyses have put an end to the controversy, confirming that treatment for varicocele significantly improves natural pregnancy rates.
Microscopic subinguinal varicocelectomy is the gold-standard option for cases of clinical varicocele and for those in which sperm analysis findings are abnormal. This approach is associated with superior efficacy outcomes, such as improvement in sperm analysis results and pregnancy rates while leading to lower rates of recurrence (< 4%) and a favorable outcome in terms of complications. It should be noted that treating subclinical varicocele is not recommended.
Specifically, microscopic subinguinal varicocelectomy improves live birth and pregnancy rates, both naturally and via in vitro fertilization. What’s more, it has a positive impact on sperm count, total and progressive motility, morphology, and DNA fragmentation levels. Overall, this surgery changes the MAR approach used in around one in two cases. The grade and unilateral or bilateral nature of varicocele are important predictive factors of improvement in sperm analysis findings and pregnancy rates associated with this interventional procedure. Treating clinical varicocele (grades 1-3) leads to improved sperm analysis results, observed in 60%-70% of cases. According to a meta-analysis, the mean increase is said to be a concentration of 12 million spermatozoids per milliliter, as well as a mean improvement of 11% in sperm motility.
Notably, embolization can be considered as an alternative to surgery. This minimally invasive X-ray-guided procedure performed by an interventional radiologist attempts to block the dilated testicular vein.
Guidelines for clinical practice in treating varicocele were recently published by the AFU’s Andrology committee.
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.