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Surgical treatment Varicocele The treatment of varicocele is a controversial subject in clini- cal andrology. This controversy is mainly based on the actual need to treat varicocele in infertile men. There is evidence of improved semen parameters after successful varicocele treatment. Current information supports the hypothesis that in some men, the presence of varicocele is associated with progressive testicular damage from adolescence onwards and consequent reduction in fertility. Although treatment of vari- cocele in adolescents may be effective, there is a significant risk of over-treatment, since many of the boys will show to be fertile later in life without varicocele treatment.

A Cochrane meta-analysis of all randomised studies of varicocele treatment in infertile men showed no benefit in terms of pregnancy from varicocele ligation. This meta- analysis also included studies of men with normal semen analysis and men with a subclinical varicoceles: in these studies there appeared to be no benefit from treatment over observation. Varicocele repair, however, may be effective in men who have a subnormal semen analysis, clinical vari- cocele and otherwise unexplained infertility. Further ran- domised studies are needed to confirm that this subgroup of infertile couples will benefit from treatment.

Microsurgery/epididymovasostomy Only urologists with experience in microsurgery should undertake this procedure. Considering its limited effect on pregnancy rates (20-30%), it is advisable to combine vaso- epididymostomy with microsurgical epididymal sperm aspi- ration (MESA), and cryopreserve the harvested spermatozoa

166 Male Infertility

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