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【讨论】对精索静脉曲张手术治疗的再思考
对精索静脉曲张手术治疗的选择:我们内的上级医生说手术有两种入路,一种是腹股沟入路,主要用于症状明里,静脉曲张显著,已生育者.第二种是髂窝入路,主要用于未生育,但精液检查有异常改变者.具他们讲以前的手术对精液改变效果都不错.不知各位站友对我们这种手术入路选择有何意见.请明示.或是手术入路只是个人爱好而已,没有区别.谢谢美国康奈尔大学医学中心统计的数据如下。表中可以发现在精索静脉曲张的各种手术方式中，显微镜下经腹股沟精索静脉结扎术是一种安全又有效的方法。值得向大家推荐。
screen.width-333)this.width=screen.width-333" width=640 height=208 title="Click to view full 各种术式.jpg (677 X 221)" border=0 align=absmiddle>显微外科精索静脉结扎术是一种理想的手术术式。该术式切口小，多选择腹股沟切口或腹股沟下切口，由于是在显微镜下操作，对手术技巧和设备有一定的要求。术中借助显微镜的优势，可以准确辨认和保留睾丸动脉、提睾肌动脉以及淋巴管，准确辨认和结扎所有的精索内静脉和引带静脉。 切口选择示意图如下：
（缩略图，点击图片链接看原图）食指扣住外环口，阑尾钳钳夹精索并轻柔上提，注意保护髂腹股沟神经和生殖股神经的生殖支，将睾丸轻轻拉出切口。
（缩略图，点击图片链接看原图）仔细检查睾丸引带，将所看到的静脉分支一一电凝或结扎。所有的精索外静脉穿支也应一一结扎。在精索静脉术后复发的病例中有10％的患者是由于引带静脉漏扎所致，这一点已经通过影像学检查得到证实。
（缩略图，点击图片链接看原图）　　我们掌握的手术原则是：1.有不育的；2.有阴囊坠胀不适的．不育患者术后的精液质量是有改善的．　　两侧的精索静脉曲张．我们首选腹腔镜手术．另外，我们正在尝试硬膜外麻醉下行腹腔镜手术，经验尚不足．望有经验者支持．当所有精索外静脉穿支和睾丸引带静脉都一一结扎后，将睾丸还纳入阴囊，继续牵拉并固定精索，在手术显微镜下进行检查。
（缩略图，点击图片链接看原图）手术显微镜下检查精索时一般选择8～15倍的放大倍数。沿精索纵行切开精索外筋膜和内筋膜，先向精索上滴上1％的罂粟碱，通过观察搏动，找到睾丸动脉，并与周围组织分离开，用1－0丝线牵开予以保护。按此方法，将发现的其他动脉血管也一一予以保护。所有精索内静脉均予以结扎。注意要将大部分的淋巴管予以保护。
（缩略图，点击图片链接看原图）手术完成的时候，精索内只剩下睾丸动脉、输精管及伴随的血管、提睾肌和精索淋巴管。该种术式需要提前进行系统的显微外科训练，因为部分手术操作是在高倍放大镜下进行的。一位有经验的医生完成一侧手术仅需要30分钟。美国康奈尔大学已经成功实施了1500例这样的手术，术后1年的怀孕率达43％，而术后2年的怀孕率则更高达69％。术后只有1％的患者出现复发，无睾丸微缩、睾丸鞘膜积液出现。（Microsurgical inguinal varicocelectomy with delivery of the testis: An artery and lymphatic sparing technique. Goldstein, et al., J. Urol., 148: , 1992）This is deleted.再将显微外科精索静脉结扎术相关的照片补充介绍一下：手术切口：
screen.width-333)this.width=screen.width-333" width=300 height=291 title="Click to view full 1.jpg (300 X 291)" border=0 align=absmiddle>Marc Goldstein, M.D. with his operating microscope at the New York Hospital-Cornell Medical Center.
screen.width-333)this.width=screen.width-333" width=300 height=204 title="Click to view full 1.jpg (300 X 204)" border=0 align=absmiddle>睾丸引带静脉和精索外静脉穿支结扎
（缩略图，点击图片链接看原图）手术显微镜下检查精索
（缩略图，点击图片链接看原图）显微镜下寻找动脉并予以保护
（缩略图，点击图片链接看原图）分离并结扎静脉
（缩略图，点击图片链接看原图）15倍显微镜下分离淋巴管并予以保护
（缩略图，点击图片链接看原图）我也说两句:我们这里腹腔镜下精索内静脉高位结扎手术就是用硬膜外麻醉,只要气腹压力设定在15mmHg以下,一般在１２左右，手术时病人并没有太多不适．镜下的精索静脉暴露非常好，手术也是很简单。只是要对镜下的解剖特别是所谓死亡三角和疼痛三角要避免损伤。还要请教腹膜后入路高未结扎复发病例是采用腹腔镜好还是内环下切口手术好？上面有战友提到精索静脉曲张的栓塞治疗，这方面的文章也不少，但在选择这种方法的时候，应清楚其优缺点，术前应向病人及家属交代清楚。下面是与开放手术进行比较的数据资料：1) Surgical VaricocelectomyBenefits:
100% occlusion rate and 5% recurrence rate 66% of men with improvement in seminal parameters 43% of men achieves a pregnancy Risks of procedure: 5% Wound infection 3% Epididymitis (inflammation of the epididymis) 3% Hydrocele formation (fluid around the testicle) 1% Nerve injury leading to numbness in groin and scrotum &1% Loss of testicle from damage to the testicular artery Post-Procedure process:
A semen analysis is checked approximately 4 months after either procedure Improvement in some aspect of the semen analysis may be noted soon after surgery and should continue to improve with time Recommendations after surgery: No heavy lifting (greater than 10 pounds) for 5-7 days No sexual activity for one week 2) Percutaneous Radiographic EmbolizationBenefits: 70% occlusion rate and 5% recurrence rate Diagnosis and treatment of subclinical varicoceles (those not seen or felt on exam) Optimal treatment after surgical failure Immediate recovery/no lifting restrictions
Risks of procedure (11%): Extravasation (catheter comes out of the vein) Allergic reactions to dye -Inflammation of the veins in the testicles from sclerosing agents Accidental puncture of femoral artery with femoral approach Venous Spasm Pain本次有关精索静脉曲张外科手术的讨论得到了广大战友的积极参与，通过讨论，使大家可以对这一简单的疾病和简单的手术进行一下必要的复习和反思。在争论中提高自己，在讨论中展现自己。医学的发展是无止境的，也是不断变化的，今天大家普遍认可的东西，也许明天就已经过时了。只要我们能够抱着谦虚好学的心态，不断追求上进的精神，就会不断的从别人那里获取最新的知识和观念，从而不断的提高自己，升华自己。今后我版还会开展类似的讨论专题，欢迎大家积极参与！正常人站位阴囊内温度最低，V曲张者站位时曲张加重，温度增高，影响生精细胞，致代谢改变，凋亡增多，支持细胞功能及血管均发生改变，A-V分流增多，DNA 合成酶活力减低，营养物和O2释出至睾丸减少。热应激和雄激素受抑制致合成功能减低，精子数减少。肾和肾上腺代谢产物
精索V血内正肾上腺素和前列腺素E、F增高，肾素、脱氢表雄酮和皮质醇无增高。肾上腺髓质素是强的血管舒张剂，存在于肾上腺、肺、肾、心脏和内皮组织内，但睾丸内却未有表达。而精索V曲张患者术中取精索V血分析，肾上腺髓质素显著增多。可增强反流热交换的阻断作用。
一般行腹膜后入路精索静脉高位结扎，复发罕见。腹股沟浅环下切口,于皮下组织下分离出精索(可将睾丸挤出或不挤,有医生挤出睾丸,将精索外静脉也结扎),然后结增粗的精索静脉,只要看到增粗的静脉就全部扎掉.
附一张超声的V曲张图
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精索静脉曲张手术结扎与血管栓塞治疗男性不育的疗效分析.CAJ (45.67k)精索静脉曲张手术能否改善精液质量既然有争议, 那么本人建议有心人来设计并实施一个大样本的随机对照试验，这个并不难，要的是认真的态度和坚持的精神。另一方面，不知道大家对单靠彩超诊断精索静脉曲张意见如何，本人是不主张症状和体征均为阴性而单靠彩超来诊断的，即使是对男性不育者。公狼 wrote:精索静脉曲张手术能否改善精液质量既然有争议, 那么本人建议有心人来设计并实施一个大样本的随机对照试验，这个并不难，要的是认真的态度和坚持的精神。另一方面，不知道大家对单靠彩超诊断精索静脉曲张意见如何，本人是不主张症状和体征均为阴性而单靠彩超来诊断的，即使是对男性不育者。公狼战友的意见很好，在国内是需要进行这样的多中心随机研究。阴囊超声及彩色多普勒影像检查仅对于那些通过物理检查无法明确的患者。通过超声检查，可以精确测量精索内静脉的管径，并在屏气时测定有无静脉血逆流。通常精索内静脉管径如大于3.5mm，则很容易通过物理检查得到诊断，如管径不超过2.7mm，则很难触及精索内静脉，这种情况被称为“亚临床型”精索静脉曲张。对于亚临床型精索静脉曲张是否需要进一步诊断和治疗，目前尚存在很大的争议。近期的研究显示，对于亚临床型精索静脉曲张进行手术治疗其价值值得怀疑。当然，也有研究者发现，当左侧静脉曲张很严重时，对右侧存在亚临床型精索静脉曲张的患者来讲，同时行右侧精索静脉结扎术是有意义的。1. Howards SS: Subclinical varicocele. Fertil Steril 57:725, 1992.2. Jarow JP, Ogle SR, Eskew LA: Seminal improvement following repair of ultrasound detected subclinical varicoceles. J Urol 155:.3. Kondoh N, Meguro N, Matsumiya K, et al: Significance of subclinical varicocele detected by scrotal sonography in male infertility: a preliminary report. J Urol 150:.4. Scherr D, Goldstein M: Comparison of bilateral vs. unilateral varicocelectomy in men with palpable bilateral varicoceles [abstract 808]. In J Urol 159:209, 1998.前次发过这个系统评价的摘要，今再次先发出全文，改天翻译过来Surgery or embolisation for varicocele in subfertile men[Review]Evers, JL; Collins, JADate of Most Recent Update: 21-May-2004Date of Most Recent Substantive Update: 04-May-2004Cochrane Menstrual Disorders and Subfertility Group.Prof. Johannes Evers, MD, Department of Obstetrics & Gynaecology, Academisch Ziekenhuis Maastricht, P.O. Box 5800, Maastricht, 6202 AZ, NETHERLANDS. Phone: +31 - 43-387 67 64, Fax: +31 - 43-387 47 65, E-mail: jev@sgyn.azm.nl, NL.Abstract Background: A varicocele is a meshwork of distended blood vessels in the scrotum, usually left-sided, due to dilatation of the spermatic vein. Although the concept that varicocele causes, and varicocelectomy cures, male subfertility has been around for almost fifty years, the mechanisms by which varicocele 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.Objectives: To evaluate the effect of varicocele treatment on pregnancy rate in subfertile couples.Search strategy: We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 12 Sept 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004) and reference lists of articles. In addition, we hand searched 22 specialist journals in the field from their first issue until 2004. We also checked cross references, references from review articles, and contacted researchers in the field.Selection criteria: 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 embolization of the internal spermatic vein) and untreated groups.Data collection and analysis: Nine studies met the inclusion criteria for this review. One was an extension of a previously published study (Nieschlag ), which left eight studies for analysis (Nilsson 1979; Breznik 1993; Madgar 1995; Yamamoto 1996; Nieschlag ; Grasso 2000; Unal 2001; Krause 2002). All eight only included men from couples with subfertility problems, one (Madgar 1995) excluded men with sperm counts &5 mill/mL, one (Krause 2002) men with sperm counts &2 mill/mL and/or progressive motility &10%, two trials involving clinical varicoceles included some men with normal semen analysis (Nilsson 1979; Breznik 1993). Three studies (Yamamoto 1996; Grasso 2000; Unal 2001) 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.Main 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 varicocele treatment over expectant management in subfertility couples in whom varicocele in the man is the only abnormal finding.Conclusions: There is no evidence that treatment of varicocele in men from couples with otherwise unexplained subfertility improves the couple's chance of conception.________________________________________Issue protocol first published 1995 Issue 2Date new studies sought but none found 01 May, 2004Date new studies found but not yet included or excluded 10 March, 2004Date new studies found and included or excluded 01 May, 2004Date reviewers' conclusions section amended 04 May, 2004Issue next stage Issue 2, 2009Issue review first published 2001 Issue 1Background A varicocele is a meshwork of distended blood vessels in the scrotum, usually left-sided, due to dilatation of the spermatic vein. Although the concept that varicocele causes, and varicocelectomy cures, male subfertility has been around for almost fifty years now, the mechanisms by which varicocele 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 relationship exists at all between the distension of the pampiniform plexus and impairment of fertility.In a multicenter study (WHO 1992) on the investigation and diagnosis of the subfertile couple, the incidence of varicocele in the male partners of subfertile couples was 11.7%, and in men with abnormal semen analysis (SA) parameters, it was 25.4%. Thus, varicocele is the most frequent physical abnormality found in subfertile men and occlusion of the left spermatic vein is accepted by many physicians as the treatment of choice for this condition (Nieschlag 1993). Estimates of the incidence of varicocele in men from the general population however, arrive at figures in the same range (15%; Saypol 1981). Yet, varicocele has been associated with abnormalities in semen parameters and implicated as a cause of male subfertility (Dubin 1977). Impaired blood drainage from the testis leading to increased scrotal temperature, hypoxia, increased testicular pressure and reflux of adrenal metabolites, with deleterious effects on spermatogenesis have been proposed as its etiology (Dubin 1975; Homonnai 1980; Pryor 1987; Segenreich 1986).The traditional method of treatment is surgical ligation of the internal spermatic vein. Several surgical techniques have been employed but retroperitoneal high ligation (initially described by Ivanissevitch, and modified by Palomo) and transinguinal ligation (as described by Bernardi) are the most frequently performed. More recently, selective catheterisation and embolisation of the internal spermatic vein with sclerosing solutions, tissue adhesives, or detachable balloons or coils, have been used as alternatives. Laparoscopic ligation has also been proposed. Many men with a varicocele have normal fertility and investigators have doubted the therapeutic value of treatment of varicocele (Rodriquez 1978; Vermeulen 1985). A review of 50 publications on a total of 5471 couples with uncompromised female fertility and a varicocele in the man (Mordel 1990) showed widely varying pregnancy rates of 0 to 50% after treatment, with a weighted mean of 36%. This is similar to the 33% spontaneous pregnancy rate in Taylor and Collins' 1992 review of 20 studies on 2026 couples with completely unexplained subfertility (Taylor 1992).Conclusions regarding the true effect of varicocelectomy on pregnancy rate can only be derived from prospective studies with an unbiased control group, preferably randomised controlled trials (RCTs). This review will attempt to examine the clinical value, in terms of pregnancy rate, of treating varicoceles in the male partner of couples with otherwise unexplained subfertility.Objectives To evaluate the effect of varicocele treatment (surgical or by embolisation) on pregnancy rate in subfertile couples where the male has a unilateral left varicocele.Criteria for considering studies for this review Types of participants Couples suffering from subfertility and where the male partner was found to have a left-sided varicocele, and normal or abnormal semen analysis. Details of duration of subfertility, investigation and age of the female partner, and previous treatment were listed whenever given. The grades of varicocele according to WHO criteria qualifying for inclusion were recorded (WHO 0, only demonstrable by technica WHO I, only palpable/visible during V WHO II, palpable when in upright position WHO III, visible when in upright position at room temperature).Types of intervention Therapeutic treatment of varicocele (surgical ligation or embolisation) versus no such treatment (or delayed treatment) in (otherwise unexplained) subfertile couples trying to achieve a pregnancy. Two trials were included that did not strictly meet this criterion, but compared therapeutic treatment of varicocele to treatments considered ineffective by the reviewers.Types of outcome measures Primary outcome: live birth.Secondary outcome: pregnancy.Semen quality was specified in the original review as a secondary outcome, but later deemed irrelevant in the presence of more clinically meaningful outcome, and therefore was omitted when updating this review.Types of studies A trial was eligible for inclusion if it dealt with the treatment of varicocele in subfertile couples and contained a control group which the authors claimed was created by a randomisation procedure and if it provided live birth (preferably) or pregnancy as an outcome. The diagnosis of varicocele was mostly on clinical grounds (palpation of the veins in the scrotum with the man in upright position during Valsalva manoeuvre). Where the clinical findings were confirmed by one of the technical diagnostic methods (such as Doppler ultrasound, phlebography, radioactive scanning, thermography), this was indicated in the trial characteristics table.Search strategy for identification of studies We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 12 September 2003), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2004), MEDLINE (January 1966 to May 2004, searched 1 May 2004), EMBASE (January 1985 to May 2004, searched 1 May 2004) and reference lists of articles.We also hand searched 22 specialist journals in the field from their first issue until 2004. We checked cross references and references from review articles. We also contacted researchers in the field.The only search term used was varicocele/varicocoele, with no constraints applied.RCTs were included if they were relevant to the clinical question of varicocele repair, if they reported pregnancy rates or (preferably) live birth 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. Authors were contacted to clarify missing details regarding their studies, however not all authors could be traced and some failed to respond.Methods of the review Study selectionTwo reviewers (JE and JC) selected studies for inclusion in the review. The titles and abstracts of articles found in the search were screened by JE, who discarded studies that were clearly ineligible. Then both reviewers independently assessed whether the studies met the inclusion criteria, with disagreements resolved by discussion. None occurred for the present review.Assessment of methodological qualityTwo reviewers (JE and JC) independently assessed the quality of all studies that were deemed eligible for the review, any discrepancies were resolved by discussion. The quality of allocation concealment was graded as adequate (A), unclear (, or inadequate (C), following the detailed descriptions of these categories provided by the Menstrual Disorders and Subfertility Review Group.Data extractionTwo reviewers (JE and JC) independently extracted data from all included studies. Discrepancies were resolved by discussion. For each included trial, information was collected regarding the location of the study, methods of the study, the participants (age range, eligibility criteria), the nature of the interventions, and data relating to the outcomes specified above. Additional information was sought, and obtained, from the Dr Nieschlag, on the randomisation procedure in his study.AnalysisStatistical analysis was performed in accordance with the guidelines for statistical analysis developed by the Cochrane Collaboration. Heterogeneity (variations) between the results of different studies was examined by inspecting the scatter in the data points on the graphs and the overlap in their confidence intervals and, more formally, by checking the results of the chi-squared tests. Where possible, the outcomes were pooled statistically. Results for each study were expressed as an odds ratio (OR) with 95% confidence intervals (CI) and combined for meta-analysis with RevMan software using the Peto method and a fixed effects model.Description of the studies The search strategy returned 23 studies. Fourteen were excluded after initial screening for a variety of reasons (see the table 'Characteristics of excluded studies'), predominantly because they concerned comparisons of technical procedures (different types of surgery, sclerosation, embolisation) and did not include an untreated comparison group. Eight studies (nine publications) with 607 participants were retained for the present review.Study characteristicsSee the table 'Characteristics of included studies' for individual studies. Patients surgically treated for varicocele were included in nine publications, eight of them single center studies, one (Krause 2002) multicenter, all of them dealing with subfertile couples. Most studies applied surgical ligation as the method of treatment in the patients randomised to the experimental group, except Breznik (Breznik 1993) and Nieschlag (Nieschlag ), which had part of the patients receiving embolisation or sclerosation treatment, and Krause (Krause 2002), which had sclerosation treatment in all patients. One study (Nieschlag ) was an extension of a previously published study (Nieschlag ), which left eight studies for analysis (Nilsson 1979; Breznik 1993; Madgar 1995; Yamamoto 1996; Nieschlag ; Grasso 2000; Unal 2001; Krause 2002). The decision to include studies which include normozoospermic men (Nilsson 1979; Breznik 1993) was based on their apparently representing a category of patients for whom varicocelectomy is deemed feasible, and by their even distribution between the experimental group and the controls. It appeared that 96 of 607 men were normozoospermic at the moment of inclusion into the study (see later). Studies comparing treatment with counselling only were included and the outcome of the counselling-only group was considered together with those of the no-treatment groups from other trials (Nieschlag ). One study that compared varicocele treatment with clomiphene citrate was included (Unal 2001) because clomiphene citrate is no more effective than vitamin C (Abel 1982), and the control group pregnancy rate was the lowest of all trials. Trials were screened and analysed for the following quality criteria: method and tim number of participants randomised, e whether they were single- or employed single phase or cross- blinding of treatment (virtually impossible in studies involving surgery); the use of sequential analysis the presence of duration of follow- whether pregnancy was an outcome measure and, if so,
how pregnancy results were presented (particularly whether cumulative conception curves with the use of life table analysis were employed); and the source of any funding.Patient characteristicsAll eight studies only included men from couples with subfertility problems. One study (Madgar 1995) excluded men with sperm counts &5 mill/mL, one (Krause 2002) excluded men with sperm counts &2 mill/mL and/or progressive motility &10%, two studies involving clinical varicoceles (Nilsson 1979 and Breznik 1993) also included men with normal semen analysis. Three studies (Yamamoto 1996; Grasso 2000; Unal 2001) specifically addressed only subfertile men with subclinical varicoceles as diagnosed by thermography or Doppler ultrasound.The two most carefully described single center studies of men with clinical varicoceles (Madgar 1995; Nieschlag ) considered patient groups that differed considerably: in the Madgar study the mean age of the male partner was 28, as compared to 32 in the Nieschlag study, and the duration of subfertility was 2 years, as compared to 4 years. Both studies lost a considerable amount of patients before randomisation. Madgar's study (Madgar 1995) considered 210 couples. Of these, 30 dropped out unwilling to complete couple evaluation and 123 did not meet the entry criteria, so 57 remained who were eligible. Of these, another 12 dropped out before randomisation, so only 45 were randomised in the end, 25 to treatment and 20 to no-treatment. None dropped out after randomisation. In Nieschlag's study (Nieschlag ) 226 couples fulfilled the entry criteria, 23 opted for IVF/ICSI, leaving 203 to be randomised. An additional 78 couples dropped out subsequently, apparently after randomisation, leaving 125 couples in the study, 63 to receive counselling only and 62 to undergo obliteration of varicocele.The WHO studyApart from these published studies, it was noted that for several years results have been presented at various meetings from a large prospective WHO multicenter study, of which the Madgar study (Madgar 1995) has been a part (WHO UNDP/UNFPA/WHO/World Bank Task Force on the prevention and treatment of infertility, project # 84902: Controlled trial of high spermatic vein ligation for varicoc WHO 1997). The results of this study, which started in 1984, still have not been published in full detail in a peer-reviewed journal and it is doubtful whether they ever will. Reports purporting to quote from this study over the past few years have given varying results, so it was not deemed appropriate to include this study into the present review without full access to its scientific details. Although in conversations with several of the study's coordinators publication was reported repeatedly to be "on course", the four years that have passed since the first publication of this review in 2000 have not allowed the authors to include this "mega-trial" since it still has not been published. The WHO data will be added if and when they become available.Methodological qualities of included studies See additional table 'Quality of Studies' (Table 01). Over all, although the included studies all included a statement about random allocation, these were not high quality studies. Only two studies (Nieschlag ; Krause 2002) described a strategy for concealment of the allocation sequence and only one (Krause 2002) included a power calculation in the Methods section. Only three of the studies (Madgar 1995; Nieschlag ; Krause 2002) did allow for an analysis of baseline characteristics and for a detailed breakdown of the numbers of couples considered for inclusion, or even fulfilling the entry criteria. Also, not all losses were always accounted for. One trial (Madgar 1995) used a randomised postponement-of-treatment design, and only data from the period before treatment in the controls have been included in the present review. Only the corresponding data (from the first 12 months following varicocelectomy) have been used for the immediate intervention group of this study (Madgar 1995). The method of randomisation was by random number generator in two studies (Nieschlag ; Krause 2002), it was not stated in the other six studies (Nilsson 1979; Breznik 1993; Madgar 1995; Yamamoto 1996; Grasso 2000; Unal 2001). All studies being (partly) surgical, none was (single or double) blinded. Blinding is virtually impossible in surgical trials, unless sham surgery is performed. All but two of the studies (Nieschlag ; Yamamoto 1996) offered or allowed for an intention-to-treat analysis. The period of untreated follow-up was 12 to 40 months in one study (Unal 2001), 12 months in five studies (Madgar 1995; Nieschlag ; Yamamoto 1996; Grasso 2000; Krause 2002) and &36 months in the other two (Nilsson 1979; Breznik 1993).Results The studies of the effect of varicocele repair on subfertility were clinically and statistically heterogeneous. The number of drop-outs after randomisation and the loss to follow-up were considerable (8 to 54%) in some (Breznik 1993; Yamamoto 1996; Nieschlag ; Krause 2002), and went unmentioned in others (Nilsson 1979; Madgar 1995; Grasso 2000; Unal 2001). Six of the eight RCTs did not state the method of randomisation (Nilsson 1979; Breznik 1993; Madgar 1995; Yamamoto 1996; Grasso 2000; Unal 2001). Two studies of men with clinical varicoceles also included normospermic varicocele patients (Nilsson 1979; Breznik 1993). One study excluded men with sperm counts &5 mill/mL (Madgar 1995), one study (Krause 2002) excluded men with &2 mill/mL and/or &10% progressive motility, three studies included men with subclinical varicoceles only (Yamamoto 1996; Grasso 2000; Unal 2001). All claimed to have excluded female subfertility factors, but not all provided sufficient details on their work-up of couples included. No indication of trials failing to reach publication was found from funnel plot analysis, from contacting experts in the field, nor from searching abstract books of scientific meetings. No studies reported the primary outcome of live birth, all eight reported pregnancy rates.The Peto OR favouring treatment over no-treatment (or counselling) is 1.10 (95%CI 0.73 to 1.68). Subgroup analysis was considered to be of questionable value, given the small numbers of patients in these studies. What the sub-group analysis showed, however, was that not showing benefit from varicocele treatment was not confined to trials involving questionable indications such as sub-clinical varicocele and normal semen analysis. Three trials were restricted to men with clinical varicoceles and abnormal semen analysis (Nieschlag ; Madgar 1995; Krause 2002). They were significantly heterogeneous and the average benefit was small with a confidence interval that included unity (Peto OR 2.08, 95% CI 0.60 to 4.25). The number needed to treat was 9 (95% CI 3 to infinity to -8).Discussion The ideal trial design would be to compare sham operation with the actual procedure. Any other design is potentially biased by the placebo effect of having the operation. However, such a trial design would be unacceptable because it would put the control group at risk from surgical and anaesthetic complications without any possibility of benefit (Hargreave 1997). Since all studies included in the present review essentially considered invasive treatment, in none had the investigator, patient, or assessor been blinded to the procedure having been performed. The outcome measures of this review, live birth and clinical pregnancy rates, were unambiguous however, so, apart from the placebo effect, no other negative factors of the lack of blinding were thought to affect the conclusions drawn.The combined Peto OR of the eight studies is 1.10 (95%CI 0.73 to 1.68). Omission of the smallest study (Madgar 1995) removes the statistical significance of the heterogeneity statistic. This study had the highest pregnancy rate in the treatment group and one of the lowest in the control group.The present review fails to offer evidence that treatment of a varicocele in men from couples with otherwise unexplained subfertility does improve the couple's spontaneous pregnancy chances. The paucity of studies, their poor methodological quality, and their clinical and statistical heterogeneity should be taken into account however. As long as it is still unclear whether it is true or not that a varicocele is "nature's attempt to heal a diseased testis rather than afflict an otherwise healthy one" (Nieschlag ), routinely treating varicoceles in men from subfertile couples seems to be ill-advised, especially if performed outside the context of a properly conducted RCT. The 'primum non nocere' (first, do no harm) principle should guide us as long as no evidence to the contrary is available.Conclusions Implications for practice Surgical or radiological treatment of varicocele in men from couples with otherwise unexplained subfertility cannot be recommended.Implications for research Although the odds ratio is close to 1.0, the 95% confidence interval is still relatively wide (i.e. it ranges from 0.73 to 1.68). The studies included in the present review of varicocele treatment are heterogeneous. This indicates a need for a large, properly conducted RCT of varicocele treatment in men with sperm defects, from couples with otherwise unexplained subfertility. The reviewers realize however that it will become increasingly difficult to conduct such a study, since the introduction of IVF/ICSI in the fertility clinic will make many men reluctant to take the risk of being allocated to the no-treatment arm of such a study, when at the same time a treatment of proven effectiveness is readily available in the form of IVF/ICSI. The issue will further be compounded by the fact that many couples tend to delay their first pregnancy nowadays, and are likely to feel that they have not much time left to spend on expectant management once they have decided, in their mid- to late thirties, to seek professional help for their fertility problem.Internal sources of support to the review * External sources of support to the review * Notes In the 2004 update three new RCTs were included in the Included Studies section of the review, one ongoing study was added to the Ongoing Studies section, and further detail was added to the narrative sections of the review.Potential conflict of interest No conflicts of interest exist.Acknowledgements Dr Patrick Vandekerckhoven was involved in preparing the 2000 version of this review.Contribution of Reviewer Johannes Evers participated in the screening of the literature, the initial data abstraction and data management, the analysis and interpretation of the data, and the preparation of the manuscript.John Collins participated in the conception and design of this review, screened the literature and did the additional data abstractions, analysed and interpreted the data and the preparation of the manuscript.Patrick Vandekerckhove was involved in preparing the 2000 version of this review.Most recent changes This review was updated in . Three new studies were included.Synopsis No evidence that treatment of varicocele in men from couples with otherwise unexplained subfertility improves pregnancy ratesVaricocele is a dilatation (enlargement) of the veins along the spermatic cord (the cord suspending the testis) in the scrotum. Dilatation occurs when valves within the veins along the spermatic cord obstruct normal blood flow, causing a backup of blood. The mechanisms by which varicocele would affect fertility have not yet been explained, and neither have the mechanisms by which surgical treatment of the varicocele might restore fertility. This review found no increase in pregnancy rates of varicocele treatment compared to no treatment in subfertile couples, in whom varicocele in the man is the only abnormal finding. (Synopsis prepared by Review Group)Table of comparisons Fig 01 Varicocele occlusion versus no treatment________________________________________ [Help with image viewing] [Email Jumpstart To Image] 01 Pregnancy rate ________________________________________Table of comparisons Fig 02 Varicocele occlusion versus no treatment in men with abnormal semen analysis and a clinical varicocele________________________________________ [Help with image viewing] [Email Jumpstart To Image] 01 Pregnancy rate ________________________________________Characteristics of included studies Study: Breznik 1993Methods: Randomised clinical trial. 96 men eligible and randomised, 17 excluded (18%; all accounted for), 79 eventually analysed. Five couples achieving pregnancy before surgery were transferred to the no-treatment group. This has been corrected for this review (see notes). More detailed intention to treat analysis not possible.Participants: Men with subclinical (thermography, phlebography) and clinical varicoceles (WHO I-III). Definition and duration of subfertility not stated. Age and infertility work-up not stated. Female causes and previous treatment excluded.Interventions: High ligation of spermatic vein (Palomo), sclerosation of spermatic vein, or Gianturco coil embolisation VERSUS no treatment.Outcomes: Pregnancy rate. Method of diagnosis not specified. Duration of follow-up 48 months (12 months in 1 treated patient).Notes: 13 pregnancies in 38 women of treated men and 22 in 41 of non-treated men, however 5 couples with pregnancy before surgery had been transferred to no-treatment group. Correction results in 18/43 and 17/36 pregnancies respectively. 25 of 79 included men had normospermia.Allocation concealment: DStudy: Grasso 2000Methods: Randomised clinical trial. 68 men randomized of an unspecified number of eligibles. All agreed not to resort to ART for 12 months.Participants: Men with subclinical (Doppler ultrasound) varicocele and low sperm quality. Clinical varicocele excluded. Definition of subfertility not stated. Duration &1 year. Female subfertility causes and previous treatment not stated.Interventions: Left spermatic vein ligation (Palomo) VERSUS no treatment.Outcomes: Paternity. Method of diagnosis not specified. Duration of follow-up 12 months.Notes: Only men aged &30 years old (range 30-38) included.Allocation concealment: DStudy: Krause 2002Methods: Randomised clinical trial. 70 men eligible, 67 randomised, 33 to sclerosation, 34 to no treatment. 34 (51%) or 36 (54%) lost to follow-up. 31 completed study. Intention To Treat analysis performed.Participants: Men from couples with &1 year subfertility, with clinical varicoceles only. Definition subfertility not stated. Exclusion: su sy genital disease (e.g. cryptorchidism); se use of drugs w sperm count &2 mill/mL; progressive motility &10%; &1 mill/mL volume &1 mL; untreated or untreatable female subfertility. Mean age men 32.2 women 29.7 years. Loss to follow-up 51% (or 54%), unaccounted for.Interventions: Retrograde or antegrade sclerosation VERSUS no treatment.Outcomes: Pregnancy rate. Method of diagnosis: ultrasound. Duration of follow-up 12 months.Notes: Multicenter trial, scheduled to include 460 men. Discontinued after 3 years because of poor recruitment (70 men in 15 enters).Allocation concealment: AStudy: Madgar 1995Methods: Randomised clinical trial, postponement-of-treatment study, part of unpublished WHO study #8 new patients, 57 eligible, 45 men randomised, 25 to treatment group, 20 to no-treatment.Participants: Inclusion: varicocele II and III, abnormal SA (&20 mill/mL, WHO). Exclusion: SA&5 mill/mL, accessory gland infection, abnormal FSH, LH or T. Definition subfertility and work-up according to WHO, duration &12 months (25.3 in treated, 26.6 in untreated group). Age 28.7 years in either group. Female factors excluded. Previous treatment not mentioned.Interventions: Surgical ligation of spermatic vein (modified Palomo) VERSUS delayed surgery (for 12 months).Outcomes: Pregnancy rate. Method of diagnosis not specified. Duration of follow-up 12 months.Notes: Only pre-treatment part in control patients taken into account for present review.Allocation concealment: DStudy: Nieschlag Methods: Randomised clinical trial. 226 men fulfilled entry criteria: 203 randomised, 23 opted for assisted reproduction. 125 completed study: 62 treated by ligation/embolisation, 63 received counseling only. 38% drop-outs after randomisation, all accounted for. Intention to treat analysis not possible.Participants: Men from couples with & 1 regular, unp Valsalva-positive varicocele (WHO grade I: n=66, grade II: n=43, grade III: n=16) and subnormal (WHO) semen analysis. Definition subfertility not stated. Exclusion: history of maldescended testes, infections, anti-sperm antibodies, general disease, chronic medication, obvious female subfertility causes (anovulation, endometriosis, tubal blockage). Mean age men 32.8 and 33.1, women 30.5 and 30.4 yrs in counseling and treatment group respectively. Lost to follow-up accounted for.Interventions: Radiological embolisation or surgical ligation VERSUS counseling only. Radiological embolisation: by histacryl tissue adhesive. Surgical ligation: by high retroperitoneal ligation according to Bernardi (1942). All men in the treatment and no-treatment group were reinvestigated and counseled after 3, 6, 9 and 12 months.Outcomes: Pregnancy rate. Method of diagnosis not specified. Duration of follow-up 12 months.Notes: During study period WHO definition of normal morphology cut-off changed from 50% to 30%. Since patient assignment was random all study groups affected equally (mean date of entry into study not different).Allocation concealment: AStudy: Nilsson 1979Methods: Randomised clinical trial. 96 men, excluded: 69 men.Participants: Inclusion: men with unilateral varicocele of couples with primary subfertility. Exclusion: previous genital or inguinal surgery, mumps orchitis during/after puberty, uni- or bilateral cryptorchidism (treated or untreated)., azoospermia, anti-sperm antibodies, raised FSH, female subfertility factors (ovulatory inadequacy, tubal blockage, cervical hostility). Diagnosis of varicocele: clinical. Duration of subfertility 2-8 yrs. Mean age treated men 31 yrs, controls 30 yrs, age women not stated.Interventions: Surgical ligation of internal spermatic vein (modified Palomo) and cremasteric vein (if varicosity of that system as well) VERSUS no treatment. Co-interventions specifically stated to have been avoided.Outcomes: Pregnancy rate. Method of diagnosis not specified. Duration follow-up: mean 53 months (range 36-74 months).Notes: Varicocele patients from subfertile couples were included, irrespective of semen analysis results. Normospermia was not an exclusion criterion, 26% men had sperm counts &20 mill/mL.Allocation concealment: DStudy: Unal 2001Methods: Randomised clinical trial. 42 men randomized, 21 to surgery, 21 to clomiphene citrate. Number eligible not stated.Participants: Inclusion: men with left subclinical (Doppler ultrasound) varicocele and normal testicular size. Clinical varicocele excluded. Definition of subfertility not stated. Duration &1 year. Fertility work-up not stated.Interventions: Surgical ligation of the spermatic vein VERSUS clomiphene citrate for 6 months.Outcomes: Pregnancy rate. Method of diagnosis: face-to-face or telephone interview, or latest clinic visit data. Duration of follow-up 12-40 months.Notes: Men taking clomiphene citrate in control group.Allocation concealment: DStudy: Yamamoto 1996Methods: Randomised clinical trial. 92 men qualified and were randomised, 45 to treatment, 47 to no-treatment group. Of the latter, 7 were lost to follow-up (8% of couples randomised), leaving 40 men for analysis in the no-treatment group. Intention to treat analysis not possible.Participants: Inclusion: left subclinical varicocele, defined as a thermographic difference of &0.3 degree Celsius and no clinical varicocele. Exclusion: previous cryptorchidism, hydrocele, testicular trauma, or surgery of the urogenital tract. Definition subfertility not stated, duration 1-5 yrs. Mean age men 32 (24-37) yrs. Age women not stated. Infertility work-up included history, physical, BBT, endocrinology, and HSG (in selected patients).Interventions: High ligation of the internal spermatic vein VERSUS no treatment.Outcomes: Pregnancy rate. Method of diagnosis not specified. Duration follow-up 12 months.Notes: Men with normospermia have been included in this study. Mean sperm density (SD) was 15.0 (18.1) and 15.1 (20.1) mill/mL in treatment and no-treatment group respectively.Allocation concealment: DDr Nieschlag provided additional information on the allocation concealment procedure in his study.Characteristics of excluded studies Study: Barbalias 1998Reason for exclusion: RCT of four different venous embolisation approaches.Study: Cayan 2000Reason for exclusion: RCT of high ligation surgery versus microsurgical high inguinal varicocelectomy.Study: Grasso 1995Reason for exclusion: RCT of bilateral versus unilateral occlusion of spermatic veins in men with bilateral varicocele.Study: Khan 2003Reason for exclusion: RCT of high versus low ligation proceduresStudy: Laven 1992Reason for exclusion: RCT in adolescents. Follow-up of testicular volume, semen analysis. No pregnancy rates.Study: Matsuda 1993Reason for exclusion: RCT of artery preservation versus ligation.Study: Nieschlag 1993Reason for exclusion: RCT of surgical ligation versus embolisation. Semen analysis, pregnancy rates.Study: Paduch 1997Reason for exclusion: RCT in adolescents. Follow-up of testicular volume. No semen analysis, no pregnancy rates.Study: Podkamenev 2002Reason for exclusion: RCT of laparoscopy versus open surgeryStudy: Sautter 2002Reason for exclusion: RCT of laparoscopy versus sclerotherapyStudy: Sayfan 1992Reason for exclusion: RCT of three techniques of varicocele repair: percutaneous embolisation, high ligation of the internal spermatic vein, and transinguinal ligation of the internal and external spermatic vein.Study: Yamamoto 1995aReason for exclusion: RCT in adolescents. Follow-up of testicular volume, semen analysis.Study: Yamamoto 1995bReason for exclusion: RCT of spermatic artery preservation versus ligation.Study: Yavetz 1992Reason for exclusion: RCT of embolisation versus surgical ligation.Characteristics of ongoing studies Study: Dohle 2003Trial name or title: Does varicocele repair result in more spontaneous pregnancies?Participants: Subfertility couples, varicocele, subnormal sperm count, azoospermia excluded. Women normal and &36 yrs.Interventions: Not stated ("varicocele treatment")Outcomes: TBAStarting date:Contact information:Notes: Abstract of interim analysis published in suppl. to J. Urol. 2003, p. 408.Table 01 Quality table Study: Breznik 1993Allocation concealed: UnclearRandomisation: UnspecifiedBlinding: NoFollow-up complete: 82%ITT 1st outcome: ITT not done, but possible.Power calculation: Not doneStudy: Grasso 2000Allocation concealed: UnclearRandomisation: UnspecifiedBlinding: NoFollow-up complete: CompleteITT 1st outcome: As allocatedPower calculation: Not doneStudy: Krause 2002Allocation concealed: Yes, by third party, central telephoneRandomisation: Random number generator, provided by telephone after registrationBlinding: NoFollow-up complete: 46%ITT 1st outcome: As allocated, and as treatedPower calculation: Prospective, correctStudy: Madgar 1995Allocation concealed: UnclearRandomisation: Not specifiedBlinding: NoFollow-up complete: CompleteITT 1st outcome: As allocatedPower calculation: Not doneStudy: Nieschlag Allocation concealed: Yes, by third partyRandomisation: Random number generator, before first patient entered study, provided in opaque envelopesBlinding: NoFollow-up complete: CompleteITT 1st outcome: As allocated, minus losses to FUPower calculation: Not doneStudy: Nilsson 1979Allocation concealed: UnclearRandomisation: Not specifiedBlinding: NoFollow-up complete: CompleteITT 1st outcome: As allocatedPower calculation: Not doneStudy: Unal 2001Allocation concealed: UnclearRandomisation: Not specifiedBlinding: NoFollow-up complete: CompleteITT 1st outcome: As allocatedPower calculation: Not doneStudy: Yamamoto 1996Allocation concealed: UnclearRandomisation: Not specifiedBlinding: NoFollow-up complete: 91%ITT 1st outcome: As allocated, minus losses to FUPower calculation: Not doneReferences to studies included in this review Breznik 1993Breznik R, Vlaisavljevic V, Borko E. Treatment of varicocele and male fertility. Archives of Andrology -60. Bibliographic Links Library Holdings [Context Link]Grasso 2000Grasso M, Lania M, Castelli M, Galli L, Franzoso F, Rigatti P. Low-grade left varicocele in patients over 30 years old: the effect of spermatic vein ligation on fertility. British Journal of Urology -7. [Context Link]Krause 2002Krause W, Muller HH, Schafer H, Weidner W. Does treatment of varicocele improve male fertility? Results of the "Deutsche Varikozelenstudie", a multicentre study of 14 collaborating centres. Andrologia -71. Bibliographic Links Library Holdings [Context Link]Madgar 1995Madgar I, Weissenberg R, Lunenfeld B, Karasik A, Goldwasser B. Controlled trial of high spermatic vein ligation for varicocele in infertile men. Fertility & Sterility -4. [Context Link]Nieschlag Nieschlag E, Hertle L, Fischedick A, Absagen K, Behre HM. Update on treatment of varicocele: counselling as effective as occlusion of the vena spermatica. Human Reproduction -4. [Context Link]Nieschlag E, Hertle L, Fischedick A, Behre HM. Treament of varicocele: counselling as effective as occlusion of the vena spermatica. Human Reproduction -53. Ovid Full Text Bibliographic LinksNilsson 1979Nilsson S, Edvinsson A, Nilsson B. Improvement of semen and pregnancy rate after ligation and division of the internal spermatic vein: fact or fiction? British Journal of Urology -6. Bibliographic Links Library Holdings [Context Link]Unal 2001Unal D, Yeni E, Verit A, Karatas OF. Clomiphene citrate versus varicocelectomy in treatment of subclinical varicocele: a prospective randomized study. International Journal of Urology -30. Bibliographic Links Library Holdings [Context Link]Yamamoto 1996Yamamoto M, Hibi H, Hirata Y, Miyake K, Ishigaki T. Effect of varicocelectomy on sperm parameters and pregnancy rate in patients with subclinical varicocele: a randomized prospective controlled study. Journal of Urology 6-8. Ovid Full Text Bibliographic Links [Context Link]References to studies excluded in this review Barbalias 1998Barbalias GA, Liatsikos EN, Nikiforidis G, Siablis D. Treatment of varicocele for male infertility: a comparative study evaluating currently used approaches. European Urology ):393-8. Bibliographic Links Library HoldingsCayan 2000Cayan C, Kadioglu TC, Tefekli A, Kadioglu A, Tellaloglu S. Camparison of results and complications of high ligation surgery and microsurgical high inguinal varicocelectomy in the treatemnt of varicocele. Urology -4. Bibliographic Links Library HoldingsGrasso 1995Grasso M, Lania C, Castelli M, Galli L, Rigatti P. Bilateral varicocele: impact of right spermatic vein ligation on fertility. Journal of Urology 7-8. Ovid Full Text Bibliographic LinksKhan 2003Khan M, Khan S, Pervez A, Nawaz H, Ahmed S, Tareen S. Evaluation of low ligation and high ligation procedures for varicocele. Journal of the College of Physicians Surgeons of Pakistan ):280-3.Laven 1992Laven JS, Haans LC, Mali WP, Te Velde ER, Wensing CJ, Eimers JM. Effects of varicocele treatment in adolescents: a randomized study. Fertility & Sterility -62.Matsuda 1993Matsuda T, Horii Y, Yoshida O. Should the testicular artery be preserved at varicocelectomy? Journal of Urology 7-60. Bibliographic Links Library HoldingsNieschlag 1993Nieschlag E, Behre HM, Schlingheider A, Nashan D, Pohl J, Fischedick AR. Surgical ligation vs. angiographic embolization of the vena spermatica: a prospective randomized study for the treatment of varicocele-related infertility. Andrologia -7. Bibliographic Links Library Holdings [Context Link]Paduch 1997Paduch DA, Niedzielski J. Repair versus observation in adolescent varicocele: a prospective study. Journal of Urology 8-32. Ovid Full Text Bibliographic LinksPodkamenev 2002Podkamenev VV, Stalmakhovich VN, Urkov PS, Solovjev AA, Iljin VP. Laparoscopic surgery for pediatric varicoceles: randomized controlled trial. Journal of Pediatric Surgery ):727-9. Bibliographic Links Library HoldingsSautter 2002Sautter T, Sulser T, Suter S, Gretener H, Hauri D. Treatment of varicocele: a prospective randomized comparison of laparoscopy versus antegrade sclerotherapy. European Urology ):398-400. Bibliographic Links Library HoldingsSayfan 1992Sayfan J, Soffer Y, Orda R. Varicocele treatment: prospective randomized trial of 3 methods. Journal of Urology 7-9. Bibliographic Links Library HoldingsYamamoto 1995aYamamoto M, Hibi H, Katsuno S, Miyake K. Effects of varicocelectomy on testis volume and semen parameters in adolescents: a randomized prospective study. Nagoya Journal of Medical Sciences -32.Yamamoto 1995bYamamoto M, Tsuji Y, Ohmura M, Hibi H, Miyake K. Comparison of artery-ligating and artery-preserving varicocelectomy: effect on postoperative spermatogenesis. Andrologia -40. Bibliographic Links Library HoldingsYavetz 1992Yavetz H, Levy R, Papo J, Yogev L, Paz G, Jaffa AJ. Efficacy of varicocele embolization versus ligation of the left internal spermatic vein for improvement of sperm quality. International Journal of Andrology -44. Bibliographic Links Library HoldingsReferences to studies awaiting assessment WHO 1997Hargreave TB. Varicocele: Overview and commentary on the results of the WHO varicocele trial. Current advances in andrology, Proceedings of the VIth International Congress of Andrology, Salzburg, Austria, May 25-29, -44Waites GMH, Frick J, Baker GWH, Monduzzi Editore S.p.a, Bologna, Italy. [Context Link]References to ongoing studies Dohle 2003Study contact information not provided. Contact author for more information. Does varicocele repair result in more spontaneous pregnancies? Ongoing study Starting date of trial not provided. Contact author for more information.Dohle GR, Pierik F, Weber RF. Does varicocele repair result in more spontaneous pregnancies? A randomised prospective trial. Journal of Urology
Suppl):408.Additional references Abel 1982Abel B, Carswell G, Elton RA, Hargreave T, Kyle K, Orr S. Randomized trial of clomiphene citrate treatment and vitamin C for male infertility. British Journal of Urology -4. Ovid Full Text Bibliographic Links [Context Link]Dubin 1975Dubin L, Amelar RD. Varicocelectomy as a therapy in male infertility: a study of 504 cases. Journal of Urology -1. Ovid Full Text Bibliographic Links [Context Link]Dubin 1977Dubin L, Amelar RD. Varicocelectomy: 986 cases in a twelve-year study. Urology -9. Bibliographic Links Library Holdings [Context Link]Hargreave 1997Hargreave TB. Varicocele: overview and commentary on the results of the World Health Organisation varicocele trial. Current Advances in Andrology, Proceedings of the VIth International Congress of Andrology, Salzburg, Austria, May 25-29, -44Waites GMH, Frick J, Baker GWH, Monduzzi Editore S.p.a, Bologna, Italy. [Context Link]Homonnai 1980Homonnai Z, Fainman N, Engelhard Y, Rudberg Z, David M, Paz G. Varicocelectomy and male fertility: comparison of semen quality and recurrence of varicocele following varicocelectomy by two techniques. International Journal of Andrology -51. Bibliographic Links Library Holdings [Context Link]Mordel 1990Mordel N, Mor-Yosef S, Margalioth EJ, Simon A. Spermatic vein ligation as treatment for male infertility. Journal of Reproductive Medicine -7. Bibliographic Links Library Holdings [Context Link]Pryor 1987Pryor J, Howards S. Varicocele. Urology Clinics of North America -506. [Context Link]Rodriquez 1978Rodriquez-Rigau LJ, Smith KD, Steinberger E. Relationship of varicocele to sperm output and fertility of male partners in infertile couples. Journal of Urology -4. Bibliographic Links Library Holdings [Context Link]Saypol 1981Saypol DC. Varicocele. Journal of Andrology -71. [Context Link]Segenreich 1986Segenreich E, Shmuely H, Singer R, Servadio C. Andrological parameters in patients with varicocele and disorders treated by high ligation of the left spermatic vein. International Journal of Fertility -3. Bibliographic Links Library Holdings [Context Link]Taylor 1992Taylor PJ, Collins JA. Unexplained Infertility 1992;Oxford University Press, Oxford. [Context Link]Vermeulen 1985Vermeulen A, Vandeweghe M, Deslypere JP. Prognosis of subfertility in men with corrected or uncorrected varicocele. Journal of Andrology -55. Bibliographic Links Library Holdings [Context Link]WHO 1992World Health Organisation. The influence of varicocele on parameters of fertility in a large group of men presenting to infertility clinics. Fertility & Sterility 9-93. [Context Link]References to previously published studies Evers 2003Evers JLH, Collins JA. Assessment of efficacy of varicocele repair for male subfertility: a systematic review. Lancet 9-52. Bibliographic Links Library HoldingsMedical Subject Headings (MeSH): F H M P *Embolization, T Infertility, Male/et (etiology); Infertility, Male/sg (surgery); *Infertility, Male/tp (therapy); Outcome Assessment/hc (Health Care); Randomized Controlled T Varicocele/cp (complications); Varicocele/sg (surgery); *Varicocele/tp (therapy)
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