The purpose of the article is to review the current concepts regarding the etiology and treatment of male-factor infertility. The following general conclusions can be drawn: (a) conventional parameters for sperm quality and male fertility are inadequate and any assessment should involve several different tests of sperm cell function to increase the fertility prognosis; (b) the causes of disturbed sperm quality are still poorly understood; (c) the role of the varicocele is still controversial but some of the discrepancies reported in the literature may be explained by the negative influence of other factors such as smoking, epididymal pathology or glandular infections operating either in conjunction or independent of the varicocele; (d) the role of chronic inflammatory processes in the reproductive organs, in particular the involvement of chronic chlamydial infections, has been underestimated, largely because it is often asymptomatic and difficult to demonstrate objectively; (e) partial androgen insensitiv...

Male Infertility: Current Concepts

Context The benefits and harms of varicocele treatment versus observation in adult infertile males are still controversial. Objective To systematically pool the evidence on outcomes of varicocele treatment (any surgical or radiological) versus observation in adult infertile men. Evidence acquisition A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Only prospective randomized and nonrandomized studies were included until November 2021. The primary outcome was pregnancy rate; the secondary outcomes were improvements in sperm concentration, normal morphology, and progressive sperm motility after treatment compared to baseline. Men ≥18 yr of age with any-grade varicoceles were included. Evidence synthesis Of 557 articles identified, 12 were eligible for inclusion, involving 1357 patients. Varicoceles were treated surgically in ten and radiologically in four studies. Varicocele treatment improved pregnancy rates (odds ratio 1.29; 95% confidence interval [CI] 1.00–1.65; p = 0.048) and sperm concentration (mean difference 12.34 million/ml, 95% CI 3.49–21.18; p = 0.006) compared with observation. Proportions of spermatozoa with normal morphology and progressive motility were not statistically different from those with observation. However, considering treatment arm only, sperm concentration, progressive motility, and normal sperm morphology were improved compared with baseline. A subgroup analysis showed that the benefit of varicocele treatment is evident in men with an abnormal semen analysis. The main limitation is represented by the heterogeneity of the included studies, mostly in terms of study population, fertility of the partner, outcome evaluation, lack of long-term outcomes, and intermediate/high risk of bias. Conclusions Treatment of any-grade varicoceles may improve pregnancy rates and sperm concentration in adult infertile men, while benefits in sperm motility and normal morphology are less clear. Patient summary In this systematic review and meta-analysis of all published prospective trials on varicocele treatment, significant evidence emerged on its benefit in terms of improved pregnancy rates and sperm concentration, while benefits in sperm motility and morphology are less clear. 

The Effect of Varicocele Treatment on Fertility in Adults: A Systematic Review and Meta-analysis of Published Prospective Trials.

Although varicocelectomy is generally believed to improve semen quality and the hamster egg penetration assay, these parameters do not correlate well with in vitro fertilization (IVF) success. The effect of varicocelectomy on IVF of human oocytes was examined on thirteen couples with normal female fertility, but severe oligozoospermia and the presence varicocele in the males with failure of fertilization preoperatively in in vitro fertilization-embryo of transfer (IVF-ET) attempts. The couples were readmitted for the IVF-ET procedure following varicocelectomy. A 31% pregnancy rate was achieved after the operation, while no pregnancies occurred before surgery. Sperm density and motility improved significantly after operation, resulting in a coinciding improved fertilization and pregnancy rates.

https://repository.kulib.kyoto-u.ac.jp/dspace/bitstream/2433/115333/1/40_683.pdf

The effect of varicocele ligation on oocyte fertilization and pregnancy after failure of fertilization in in vitro fertilization-embryo transfer.

Among factors accepted to cause impairment of sperm quality, clinical as well as subclinical varicoceles are the most common since they are detected in approximately one third of subfertile men. Several hypotheses have been proposed to explain the mechanism of epididymo-testicular dysfunction in these men. An important problem with the majority of these theories resides in the fact that they do not account for the observation that varicocele may have such a variable influence on testicular function, as to leaving it apparently unaltered in some cases and causing a total arrest of spermatogenesis and/or deficient androgen production in others.

The pathogenesis of epididymo-testicular dysfunction in varicocele: factors other than temperature.

PURPOSE
The purpose of this meta-analysis is to study the impact of varicocele repair in the largest cohort of infertile males with clinical varicocele by including all available studies, with no language restrictions, comparing intra-person conventional semen parameters before and after the repair of varicoceles.


MATERIALS AND METHODS
The meta-analysis was performed according to PRISMA-P and MOOSE guidelines. A systematic search was performed in Scopus, PubMed, Cochrane, and Embase databases. Eligible studies were selected according to the PICOS model (Population: infertile male patients with clinical varicocele; Intervention: varicocele repair; Comparison: intra-person before-after varicocele repair; Outcome: conventional semen parameters; Study type: randomized controlled trials [RCTs], observational and case-control studies).


RESULTS
Out of 1,632 screened abstracts, 351 articles (23 RCTs, 292 observational, and 36 case-control studies) were included in the quantitative analysis. The before-and-after analysis showed significant improvements in all semen parameters after varicocele repair (except sperm vitality); semen volume: standardized mean difference (SMD) 0.203, 95% CI: 0.129-0.278; p<0.001; I²=83.62%, Egger's p=0.3329; sperm concentration: SMD 1.590, 95% CI: 1.474-1.706; p<0.001; I²=97.86%, Egger's p<0.0001; total sperm count: SMD 1.824, 95% CI: 1.526-2.121; p<0.001; I²=97.88%, Egger's p=0.0063; total motile sperm count: SMD 1.643, 95% CI: 1.318-1.968; p<0.001; I²=98.65%, Egger's p=0.0003; progressive sperm motility: SMD 1.845, 95% CI: 1.537%-2.153%; p<0.001; I²=98.97%, Egger's p<0.0001; total sperm motility: SMD 1.613, 95% CI 1.467%-1.759%; p<0.001; l2=97.98%, Egger's p<0.001; sperm morphology: SMD 1.066, 95% CI 0.992%-1.211%; p<0.001; I²=97.87%, Egger's p=0.1864.


CONCLUSIONS
The current meta-analysis is the largest to date using paired analysis on varicocele patients. In the current meta-analysis, almost all conventional semen parameters improved significantly following varicocele repair in infertile patients with clinical varicocele.

Does Varicocele Repair Improve Conventional Semen Parameters? A Meta-Analytic Study of Before-After Data.

Clinical aspects in the surgical treatment of varicocele in subfertile men. II. The role of the epididymal factor

Clinical aspects in the surgical treatment of varicocele in subfertile men. I. Comparison of observed and expected pregnancy rates.

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Clinical aspects in the surgical treatment of varicocele in subfertile men. II. The role of the epididymal factor

Clinical aspects in the surgical treatment of varicocele in subfertile men. I. Comparison of observed and expected pregnancy rates.