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. 2023 Apr;41(2):289-310.
doi: 10.5534/wjmh.220142. Epub 2022 Oct 28.

Impact of Varicocele Repair on Semen Parameters in Infertile Men: A Systematic Review and Meta-Analysis

Ashok Agarwal  1 , Rossella Cannarella  2   3 , Ramadan Saleh  4 , Florence Boitrelle  5   6 , Murat Gül  7 , Tuncay Toprak  8 , Gianmaria Salvio  9 , Mohamed Arafa  10   11 , Giorgio I Russo  12 , Ahmed M Harraz  13   14   15 , Rajender Singh  16 , Nicolas Garrido  17 , Taha Abo-Almagd Abdel-Meguid Hamoda  18   19 , Amarnath Rambhatla  20 , Parviz Kavoussi  21 , Shinnosuke Kuroda  3 , Gökhan Çalik  22 , Pallavi Saini  16 , Erman Ceyhan  23 , Fotios Dimitriadis  24 , Ralf Henkel  25   26   27 , Andrea Crafa  2 , Ayad Palani  28 , Mesut Berkan Duran  29 , Evangelos Maziotis  30   31 , Émine Saïs  5   6 , Marion Bendayan  5   6 , Mahsa Darbandi  32   33 , Tan V Le  34   35 , Sezgin Gunes  36 , Petroula Tsioulou  30 , Pallav Sengupta  37 , Berk Hazir  38 , Gökhan Çeker  39   40 , Sara Darbandi  32   33 , Damayanthi Durairajanayagam  41 , Azin Aghamajidi  42 , Noora Alkhalidi  43 , Emrullah Sogutdelen  44 , Kristian Leisegang  45 , Abdullah Alarbid  14 , Christopher C K Ho  46 , Vineet Malhotra  47 , Federica Finocchi  9   48 , Luís Crisóstomo  49   50   51 , Raghavender Kosgi  52 , Haitham ElBardisi  10   11 , Armand Zini  53 , Ponco Birowo  54 , Giovanni Colpi  55 , Hyun Jun Park  56   57 , Ege Can Serefoglu  58 , Quang Nguyen  59   60 , Edmund Ko  61 , Jean de la Rosette  62 , Germar M Pinggera  63 , Ho Vinh Phuoc Nguyen  34   35 , Hussein Kandil  64 , Rupin Shah  65
Affiliations

Impact of Varicocele Repair on Semen Parameters in Infertile Men: A Systematic Review and Meta-Analysis

Ashok Agarwal et al. World J Mens Health. 2023 Apr.

Abstract

Purpose: Despite the significant role of varicocele in the pathogenesis of male infertility, the impact of varicocele repair (VR) on conventional semen parameters remains controversial. Only a few systematic reviews and meta-analyses (SRMAs) have evaluated the impact of VR on sperm concentration, total motility, and progressive motility, mostly using a before-after analytic approach. No SRMA to date has evaluated the change in conventional semen parameters after VR compared to untreated controls. This study aimed to evaluate the effect of VR on conventional semen parameters in infertile patients with clinical varicocele compared to untreated controls.

Materials and methods: A literature search was performed using Scopus, PubMed, Embase, and Cochrane databases following the Population Intervention Comparison Outcome (PICOS) model (Population: infertile patients with clinical varicocele; Intervention: VR [any technique]; Comparison: infertile patients with clinical varicocele that were untreated; Outcome: sperm concentration, sperm total count, progressive sperm motility, total sperm motility, sperm morphology, and semen volume; Study type: randomized controlled trials and observational studies).

Results: A total of 1,632 abstracts were initially assessed for eligibility. Sixteen studies were finally included with a total of 2,420 infertile men with clinical varicocele (1,424 patients treated with VR vs. 996 untreated controls). The analysis showed significantly improved post-operative semen parameters in patients compared to controls with regards to sperm concentration (standardized mean difference [SMD] 1.739; 95% CI 1.129 to 2.349; p<0.001; I²=97.6%), total sperm count (SMD 1.894; 95% CI 0.566 to 3.222; p<0.05; I²=97.8%), progressive sperm motility (SMD 3.301; 95% CI 2.164 to 4.437; p<0.01; I²=98.5%), total sperm motility (SMD 0.887; 95% CI 0.036 to 1.738; p=0.04; I²=97.3%) and normal sperm morphology (SMD 1.673; 95% CI 0.876 to 2.470; p<0.05; I²=98.5%). All the outcomes showed a high inter-study heterogeneity, but the sensitivity analysis showed that no study was sensitive enough to change these results. Publication bias was present only in the analysis of the sperm concentration and progressive motility. No significant difference was found for the semen volume (SMD 0.313; 95% CI -0.242 to 0.868; I²=89.7%).

Conclusions: This study provides a high level of evidence in favor of a positive effect of VR to improve conventional semen parameters in infertile men with clinical varicocele. To the best of our knowledge, this is the first SRMA to compare changes in conventional semen parameters after VR with changes in parameters of a control group over the same period. This is in contrast to other SRMAs which have compared semen parameters before and after VR, without reference to a control group. Our findings strengthen the available evidence and have a potential to upgrade professional societies' practice recommendations favoring VR to improve conventional semen parameters in infertile men.

Keywords: Male infertility; Semen; Varicocele.

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Conflict of interest statement

The authors have nothing to disclose.

Figures

Fig. 1
Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow-chart.
Fig. 2
Fig. 2. Forest plot of the semen volume in infertile men with varicocele repair compared to no treatment.
Fig. 3
Fig. 3. Forest plot of the semen volume in infertile men with varicocele repair compared to no treatment: sensitivity analysis.
Fig. 4
Fig. 4. Funnel plot of the semen volume in infertile men with varicocele repair compared to no treatment.
Fig. 5
Fig. 5. Forest plot of the semen volume in infertile men with varicocele repair compared to no treatment: cumulative analysis.
Fig. 6
Fig. 6. Forest plot of the sperm concentration in infertile men with varicocele repair compared to no treatment.
Fig. 7
Fig. 7. Forest plot of the sperm concentration in infertile men with varicocele repair compared to no treatment: sensitivity analysis.
Fig. 8
Fig. 8. Funnel plot of the sperm concentration in infertile men with varicocele repair compared to no treatment.
Fig. 9
Fig. 9. Forest plot of the sperm concentration in infertile men with varicocele repair compared to no treatment: cumulative analysis.
Fig. 10
Fig. 10. Forest plot of the total sperm count in infertile men with varicocele repair compared to no treatment.
Fig. 11
Fig. 11. Forest plot of the total sperm count in infertile men with varicocele repair compared to no treatment: sensitivity analysis.
Fig. 12
Fig. 12. Funnel plot of the total sperm count in infertile men with varicocele repair compared to no treatment.
Fig. 13
Fig. 13. Forest plot of the total sperm count in infertile men with varicocele repair compared to no treatment: cumulative analysis.
Fig. 14
Fig. 14. Forest plot of the progressive sperm motility in infertile men with varicocele repair compared to no treatment.
Fig. 15
Fig. 15. Forest plot of the progressive sperm motility in infertile men with varicocele repair compared to no treatment: sensitivity analysis.
Fig. 16
Fig. 16. Funnel plot of the progressive sperm motility in infertile men with varicocele repair compared to no treatment.
Fig. 17
Fig. 17. Forest plot of the progressive sperm motility in infertile men with varicocele repair compared to no treatment: cumulative analysis.
Fig. 18
Fig. 18. Forest plot of the total sperm motility in infertile men with varicocele repair compared to no treatment.
Fig. 19
Fig. 19. Forest plot of the total sperm motility in infertile men with varicocele repair compared to no treatment: sensitivity analysis.
Fig. 20
Fig. 20. Funnel plot of the total sperm motility in infertile men with varicocele repair compared to no treatment.
Fig. 21
Fig. 21. Forest plot of the total sperm motility in infertile men with varicocele repair compared to no treatment: cumulative analysis.
Fig. 22
Fig. 22. Forest plot of the sperm morphology in infertile men with varicocele repair compared to no treatment.
Fig. 23
Fig. 23. Forest plot of the sperm morphology in infertile men with varicocele repair compared to no treatment: sensitivity analysis.
Fig. 24
Fig. 24. Funnel plot of the sperm morphology in infertile men with varicocele repair compared to no treatment.
Fig. 25
Fig. 25. Forest plot of the sperm morphology in infertile men with varicocele repair compared to no treatment: cumulative analysis.
Fig. 26
Fig. 26. Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis. RCT: randomized controlled trial, VR: varicocele repair.
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