Surgery for Male Infertility Ineffective
But Backers of Varicocele Repair Disagree
A surgical procedure to treat the most common cause of male infertility is not effective and should not be used, according to researchers who conducted an analysis of past studies.
The analysis found little improvement in pregnancy rates among the partners of infertile men who had varicocele repair -- surgery to repair enlarged, or varicose, veins in the scrotum. But experts who favor varicocele repair say the new analysis is badly flawed.
Varicoceles are enlargements of veins inside the scrotum that drain the testicles. These enlargements may lead to a rise in temperature and a decrease in blood circulation through the testes, and can hurt sperm production. But their exact role in male infertility is not known.
As many as 15% of all men are believed to have varicoceles. But up to 40% of infertile men have them.
In this review, researchers reanalyzed data from seven previously published trials assessing the impact of varicocele repair on pregnancy rates. There was a 1% improvement in pregnancy rates among the partners of men who had varicocele repair, compared with men who received no treatment. The findings are reported May 31 in The Lancet.
"There does not seem to be any value in doing [varicocele repair] as far as fertility is concerned," analysis co-author John A. Collins, MD, of Ontario's McMaster University, tells WebMD. "There is just very little evidence suggesting that it is effective."
But urologist Lawrence Ross, MD, points out that the authors themselves concede that the strength of their analysis is limited by the quality of the studies they included. He says the failure to consider female infertility factors in the analysis and the inclusion of men with both an obvious varicocele on physical exam and varicoceles detected through the use of ultrasound and other methods weakens the findings. The mere presence of a varicocele does not require surgery, and varicocele can be present without effecting male fertility. Ross heads the department of urology at the University of Illinois at Chicago.
He cites a joint report on varicocele repair released in 2001 by the American Urology Association and the American Society of Reproductive Medicine. The committee reported that there were not enough controlled studies to do an appropriate analysis of the procedure for male infertility, but concluded that varicocele repair is an appropriate option for men with a low sperm count and a clinical varicocele who are trying to conceive.
"The bottom line is that this study doesn't add anything to what we already know, which is that we need better ... studies to show that this is a useful treatment," he says. "The problem with fertility treatments like this one is that it is next to impossible to do these studies, because couples trying to achieve a pregnancy don't want to be in a non-treatment group."
Society for Male Reproduction and Urology President Susan Benoff, MD, is researching genetic and environmental factors that may combine with varicocele to cause male infertility. One goal, she says, is to discover ways to make varicocele repair more effective.
She argues that varicocele repair makes economic sense because for some couples it may eliminate the need for more costly interventions such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). One study suggested that the cost per live birth was three to five times higher with IVF and ICSI than with varicocele repair.
"Male infertility is a complex issue, and you have a mixed bag of men with different problems," she says. "It makes no sense to say that none of them will benefit from this surgical procedure."