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Incidence and Clinical Significance of Subclinical Scrotal Varicoceles
0022-534 7/89/1416-1372$02.00/0 Vol. 141, June
THE JOURNAL OF UROLOGY
Copyright© 1989 by Williams & Wilkins
Printed in U.S.A.
INCIDENCE AND CLINICAL SIGNIFICANCE OF SUBCLINICAL SCROTAL VARICOCELES MARK A. YARBOROUGH, JOHN R. BURNS
AND
FREDERICK S. KELLER
From the Division of Urology, Departments of Surgery and Radiology, University of Alabama and Veterans Administration Hospital, Birmingham, Alabama
ABSTRACT
A total of 40 infertile men with a normal physical examination underwent gonadal venography to determine the presence of a subclinical varicocele. Of the patients 19 had a left and 3 had a right subclinical varicocele. A total of 21 patients underwent radiographic occlusion of the varicoceles, while 1 required surgical ligation of the internal spermatic vein. Of the 22 patients 13 have been followed for greater than 6 months after correction of the varicocele. In these patients there has been a small but significant increase in sperm number after varicocele occlusion. No significant changes in either sperm motility or morphology have occurred. Although most patients do not have any major improvement after occlusion of a subclinical varicocele, some may experience a significant improvement in sperm number after occlusion. The effect on pregnancy rates is not yet known. (J. Ural., 141: 1372-1374, 1989) Scrotal varicoceles are present in approximately 15 per cent of the general male population. Varicoceles reportedly are found in up to 39 per cent of all infertile men and are the most common correctable cause of male infertility .1• 2 The role of the subclinical scrotal varicocele in male infertility has been the subject of several recent reports. 3 • 4 While some authors believe that the subclinical varicocele is an important cause of male infertility, others believe that the treatment of subclinical varicocele is not indicated. Subclinical varicoceles have been diagnosed with a variety of techniques, including Doppler studies, isotope scans, thermography, ultrasound and venography. The varying sensitivity of these different techniques probably explains why the reported incidence of subclinical varicocele varies from 12 to 75 per cent. 5 - 8 We documented the incidence of subclinical varicocele in a population of infertile men without clinical varicocele. We also report on the results of occlusion of subclinical varicoceles with regard to changes in seminal characteristics. MATERIALS AND METHODS
The 40 men who were referred to our clinic for evaluation of infertility had had abnormal seminal parameters on at least 2 semen analyses. Of the patients 26 consistently had sperm counts of less than 20 million per cc, including 13 who had sperm motility of less than 30 per cent. A total of 13 patients had initial sperm counts of greater than 20 million per cc but they had persistently poor motility (less than 30 per cent). A careful history revealed no obvious cause of the infertility. Serum follicle-stimulating hormone was normal in all patients. Routine physical examination of each patient included careful palpation of the scrotum with the patient standing, and with and without a Valsalva maneuver. None of the patients had evidence of a clinical varicocele. With their informed consent all patients underwent bilateral gonadal venography as outpatients. The procedure was performed transfemorally in 38 patients, while a transjugular approach was required in 2 whose right gonadal veins could not be catheterized via a transfemoral approach. To examine for a left scrotal varicocele, left renal venography was performed during a vigorous Valsalva maneuver with the patient in the supine position. Retrograde flow into the gonadal vein and scrotum was considered evidence of a varicocele. If a competent Accepted for publication November 8, 1988. Supported by the Veterans Administration.
valve was identified at the origin of the gonadal vein no further injections were performed. However, if a competent valve was seen proximal to the junction of the left gonadal and left renal veins the gonadal vein was catheterized, and a second injection was made during a Valsalva maneuver with the tip of the catheter just proximal to the competent valve. To examine for a right scrotal varicocele the right gonadal vein was entered and the catheter was advanced only several mm. to avoid bypassing a valve and erroneously diagnosing right subclinical varicocele. Venography then was performed during a vigorous Valsalva maneuver. If a competent valve was identified no further injections were performed. The anatomy of the varicocele and the ease of catheterization affected how occlusion of the internal spermatic vein was performed. In 19 patients multiple coil springs were deposited deep in the gonadal vein (fig. 1). In 2 patients multiple small veins originated from 1 major gonadal vein and we used boiling contrast medium for occlusion, while in 1 whose venous pattern precluded radiographic occlusion (fig. 2) we ligated the varicocele surgically through an inguinal approach. No complications occurred after either radiographic or surgical occlusion. Injections immediately afterwards showed occlusion of the vein to be complete in all patients. We did not perform late followup venograms to document the success of occlusion, since additional invasive tests could not be justified. After occlusion, all patients had followup appointments every 3 months. Semen analysis was performed at each visit. RESULTS
Of the 40 patients who underwent venography 22 (55 per cent) had a subclinical varicocele: 19 (86 per cent) on the left and 3 (14 per cent) on the right sides. No patient had bilateral subclinical varicocele. When the results were analyzed we first compared the patients with a subclinical varicocele to those with a normal venogram. The age and duration of infertility were similar in both groups. We then compared the pre-treatment sperm counts, motility and morphology in the 2 groups (table 1). With a Student t test no significant differences were found in any of the 3 parameters, indicating that the 2 groups were similar in composition (p >0.05). Of the 22 patients with a subclinical varicocele at least a 6month followup was available in 13. At least 2 semen analyses were performed after occlusion in each patient. The seminal
1372
1373
SUBCLINICAL SCROTAL VARICOCELES TABLE
1. Comparison of patients with and without a subclinical
varicocele before venography No. pts. Age Duration of infertility (yrs.) Sperm count (million/cc) Motility(%) Normal morphology(%)
TABLE 2.
Varicocele
No Varicocele
22 32.4 3.6 14.1 36.7 52.8
18 32.5 5.1 18.4 29.7 55.5
Comparison of mean seminal parameters before and after varicocele occlusion in 13 patients
Sperm number (million/cc) Motility(%) Normal morphology(%)
Pre-Treatment
After Occlusion
14.1 ± 3.9 36.7 ± 3.6 52.8 ± 2.4
20.2* ± 5.8 39.2 ± 4.4 55.9 ± 4.7
Mean ± standard error of mean.
* p <0.05 compared to pre-treatment number.
FIG. 1. A, scrotal varicocele with single internal spermatic vein. B, repeat injection after occlusion with coil springs.
less than 5 million per cc, the sperm count did not improve significantly after occlusion. DISCUSSION
FIG. 2. Internal spermatic veins originating near kidney, making occlusion impossible.
parameters of these 13 patients before and after varicocele correction were compared with paired t testing (table 2). In this analysis the pre-treatment counts, motility and morphology for each patient were averaged to determine a mean value for each parameter. Semen analyses after occlusion were averaged in a similar manner, and the mean values before and after treatment then were compared. There was a significant increase in sperm number after varicocele occlusion. No significant changes were noted in either sperm motility or morphology. Of the 13 patients 4 had an increase of more than 100 per cent in sperm number after varicocele occlusion. In patients who initially had a count of
Scrotal varicoceles were implicated in male infertility at least as long ago as 1889. 9 In 1965 MacLeod described the characteristic semen changes associated with varicoceles, that is decreased sperm count, decreased sperm motility and alteration in sperm morphology. 10 However, those changes are found in many patients who visit infertility clinics and are not peculiar to those with varicocele. In 1971 Dubin and Amelar reported on a large series of infertile men and found that clinical varicoceles occurred in 39 per cent. 2 Initial reports indicated that most clinical varicoceles occurred on the left side. In 1975 Dubin and Amelar reported on 504 varicocelectomies diagnosed by palpation alone. 11 Of these patients 86 per cent had a left varicocele, while bilateral varicocele was found in 14 per cent. By 1984, however, these numbers had changed dramatically. In a series of 870 varicocelectomies performed between 1980 and 1981 Amelar and Dubin found that 40 per cent were on the left and 4 per cent on the right sides, while 56 per cent of the patients had bilateral varicocele. 12 As in their previous study the diagnosis of a clinical varicocele was based solely on physical examination. It would appear that even in experienced hands the diagnosis of a clinical varicocele often is difficult. This high incidence of previously missed right varicoceles has been implicated in the failure of seminal characteristics to improve after unilateral left varicocelectomy.12 Numerous techniques have been used to aid in the diagnosis of a scrotal varicocele, including Doppler techniques, scrotal thermography, radionuclide scanning, scrotal ultrasound and gonadal venography. Although gonadal venography is considered the most accurate means of diagnosis, it is used only infrequently because it is invasive. 13 However, it has gained in popularity since the reports of successful radiographic occlusion of scrotal varicoceles-a varicocele currently can be diagnosed and corrected at the same time. The addition of the aforementioned diagnostic tools has resulted in an increase in the reported incidence of varicocele among infertile men. These diagnostic tools also have made the distinction between clinical and subclinical varicoceles less clear. In our series 48 per cent of the patients who appeared to be normal on physical examination had subclinical left varicocele, a figure in agreement with other recent reports. 6 · 7 However, the 7 per cent incidence of subclinical right varicocele in our group was much lower than the 44 to 62 per cent found in some other reports. 5 • 6 The difference probably is a function of the diagnostic tests used and the technical aspects of individual applications. The success of gonadal venography depends heavily on the technique of the radiologist but it generally is ac-
1374
YARBOROUGH, BURNS AND KELLER
cepted to be more sensitive than Doppler ultrasound or scrotal contact thermography in diagnosing a varicocele. 13 In a review of 42 autopsy specimens Nadel and associates found that the valve in the internal spermatic vein usually originated within 1 cm. of the origin of the vein. 14 If the angiographic catheter is placed too far into the internal spermatic vein the valve will be bypassed and a varicocele diagnosed incorrectly. That is especially important on the right side where the internal spermatic vein originates from the vena cava. Improper technique can readily explain the differences in the reported incidence of subclinical right varicoceles. · It generally has been accepted that occlusion or ligation of a clinical varicocele results in better seminal characteristics and a higher pregnancy rate than those in control subjects. 10• 11 • 15- 17 However, the criteria for improvement often were poorly defined and many of the reports failed to use a control group for comparison. Doubt recently has been cast on the efficacy of varicocele correction by failure of investigators to show significant improvement in either seminal characteristics or pregnancy rates. 13- 21 Vermeulen and associates showed not only that cumulative pregnancy rates were similar in treated and control groups but that no seminal characteristics had improved in patients who underwent varicocele correction and achieved pregnancy. 22 The role of the subclinical varicocele in male infertility is controversial. Previous investigators have reported improvement in seminal quality in approximately 50 per cent of the patients with corrected subclinical varicoceles. 3 •4 In our 13 patients with a minimum 6-month followup there was a significant increase in sperm number, with the average count increasing from 14.1 to 20.2 million per cc. Varicocele occlusion had no discernible effect on sperm motility or morphology. It should be emphasized that statistical improvement does not always constitute clinical improvement. Increasing the average sperm number from 14.1 to 20.2 million per cc may have no meaningful effect on pregnancy rates. Pregnancy rates of 32 to 50 per cent have been reported after occlusion or surgical ligation of subclinical varicoceles. 7 • 23 To date only 1 couple in our series has become pregnant and that pregnancy resulted in a miscarriage. Because we treated all patients with subclinical varicoceles we do not have an untreated control group for comparison; lack of such a control group will make it impossible for us to determine whether correction of subclinical varicoceles results in an increase in the pregnancy rate. Even if a control group was present interpretation would remain difficult, since in many of our patients the spouse also is being treated concurrently for infertility. We also should note that this study only looks at sperm number, motility and morphology. Newer tests, such as the sperm penetration assay, might be useful to evaluate the benefit of correction of subclinical varicoceles. This assay has proved to be useful to define the role of varicocele correction in patients with a clinical varicocele. 24 Burke recently reported that although the normally measured characteristics of sperm number, motility and morphology did not change after varicocele correction, there was a significant increase in sperm velocity. 25 This may have a beneficial effect on pregnancy rates. We conclude that approximately 55 per cent of all infertile men with no evidence of a clinical varicocele will have a subclinical varicocele documented with venography. In our small group of patients varicocele occlusion resulted in a small but statistically significant increase in sperm number. The effect of this increase on pregnancy rate is unknown. A patient occasionally will have a substantial increase in sperm count after occlusion. In the patient who does not have a clinically apparent varicocele and who has failed to improve on conventional medical therapy gonadal venography could be considered.
However, the patient should be made aware that occlusion of the subclinical varicocele may not enhance the chances of fertility. REFERENCES
1. Greenberg, S. H.: Varicocele and male fertility. Fertil. Steril., 28: 699, 1977. 2. Dubin, L. and Amelar, R. D.: Etiologic factors in 1,294 consecutive cases of male infertility. Fertil. Steril., 22: 469, 1971. 3. Marsman, J. W. P.: Clinical versus subclinical varicocele~ venographic findings and improvement of fertility after embolization. Radiology, 155: 635, 1985. 4. Reisner, G. and Bell, K. W.: Testicular vein venography in the infertile male. Brit. J. Urol., 51: 420, abstract, 1979. 5. Morag, B., Rubinstein, Z. J., Goldwasser, B., Yerushalmi, A. and Lunnenfeld, B.: Percutaneous venography and occlusion in the management of spermatic varicoceles. Amer. J. Roentgen., 143: 635, 1984. 6. Narayan, P., Amplatz, K. and Gonzalez, R.: Varicocele and male subfertility. Fertil. Steril., 36: 92, 1981. 7. Comhaire, F. H. and Kunnen, M.: Factors affecting the probability of conception after treatment of subfertile men with varicocele by transcatheter embolization with Bucrylate. Fertil. Steril., 43: 781, 1985. 8. Tinga, D. J., Jager, S., Bruijnen, C. L. A. H., Kremer, J. and Mensink, H. J.: Factors related to semen improvement and fertility after varicocele operation. Fertil. Steril., 41: 404, 1984. 9. Bennett, W. H.: Varicocele, particularly with reference to its radical cure. Lancet, 1: 261, 1889. 10. MacLeod, J.: Seminal cytology in the presence ofvaricocele. Fertil. Steril., 16: 735, 1965. 11. Dubin, L. and Amelar, R. D.: Varicocelectomy as therapy in male infertility: a study of 504 cases. Fertil. Steril., 26: 217, 1975. 12. Amelar, R. D. and Dubin, L.: Right varicocelectomy in selected infertile patients who have failed to improve after previous left varicocelectomy. Fertil. Steril., 47: 833, 1987. 13. World Health Organization: Comparison among different methods for the diagnosis of varicocele. Fertil. Steril., 43: 575, 1985. 14. Nadel, S. N., Hutchins, G. M., Albertsen, P. C. and White, R. I., Jr.: Valves of the internal spermatic vein: potential for misdiagnosis ofvaricocele by venography. Fertil. Steril., 41: 479, 1984. 15. Stewart, B. H.: Varicocele in infertility: incidence and results of surgical therapy. J. Urol., 112: 222, 1974. 16. Soffer, Y., Ron-El, R., Sayfan, J. and Caspi, E.: Spermatic vein ligation in varicocele: prognosis and associated male and female infertility factors. Fertil. Steril., 40: 353, 1983. 17. Marks, J. L., McMahon, R. and Lipshultz, L. I.: Predictive parameters of successful varicocele repair. J. Urol., 136: 609, 1986. 18. Nilsson, S., Edvinsson, A. and Nilsson, B.: Improvement of semen and pregnancy rate after ligation and division of the internal spermatic vein: fact or fiction? Brit. J. Urol., 51: 591, 1979. 19. Vermeulen, A. and Vandeweghe, M.: Improved fertility after varicocele correction: fact or fiction? Fertil. Steril., 42: 249, 1984. 20. Rodriguez-Rigau, L. J., Smith, K. D. and Steinberger, E.: Relationship of varicocele to sperm output and fertility of male partners in infertile couples. J. Urol., 120: 691, 1978. 21. Baker, H. W. G., Burger, H. G., de Krester, D. M., Hudson, B., Rennie, G. C. and Straffon, W. G.: Testicular vein ligation and fertility in men with varicoceles. Brit. Med. J., 291: 1678, 1985. 22. Vermeulen, A., Vandeweghe, M. and Deslypere, J.P.: Prognosis of subfertility in men with corrected or uncorrected varicocele. J. Androl., 7: 147, 1986. 23. Fogh-Andersen, P., Nielsen, N. C., Rebbe, H. and Stakeman, G.: The effect on fertility of ligation of the left spermatic vein in men without clinical signs of varicocele. Acta Obst. Gynec. Scand., 54: 29, 1975. 24. Rogers, B. J., Mygatt, G. G., Soderdahl, D. W. and Hale, R. W.: Monitoring of suspected infertile men with varicocele by the sperm penetration assay. Fertil. Steril., 44: 800, 1985. 25. Burke, R. K.: Sperm velocity, pre and post capacitation, as a measure of the effects ofvaricocelectomy. Fertil. Steril., program supplement, p. 47, abstract 131, 1986.
THE JOURNAL OF UROLOGY
Copyright© 1989 by Williams & Wilkins
Printed in U.S.A.
INCIDENCE AND CLINICAL SIGNIFICANCE OF SUBCLINICAL SCROTAL VARICOCELES MARK A. YARBOROUGH, JOHN R. BURNS
AND
FREDERICK S. KELLER
From the Division of Urology, Departments of Surgery and Radiology, University of Alabama and Veterans Administration Hospital, Birmingham, Alabama
ABSTRACT
A total of 40 infertile men with a normal physical examination underwent gonadal venography to determine the presence of a subclinical varicocele. Of the patients 19 had a left and 3 had a right subclinical varicocele. A total of 21 patients underwent radiographic occlusion of the varicoceles, while 1 required surgical ligation of the internal spermatic vein. Of the 22 patients 13 have been followed for greater than 6 months after correction of the varicocele. In these patients there has been a small but significant increase in sperm number after varicocele occlusion. No significant changes in either sperm motility or morphology have occurred. Although most patients do not have any major improvement after occlusion of a subclinical varicocele, some may experience a significant improvement in sperm number after occlusion. The effect on pregnancy rates is not yet known. (J. Ural., 141: 1372-1374, 1989) Scrotal varicoceles are present in approximately 15 per cent of the general male population. Varicoceles reportedly are found in up to 39 per cent of all infertile men and are the most common correctable cause of male infertility .1• 2 The role of the subclinical scrotal varicocele in male infertility has been the subject of several recent reports. 3 • 4 While some authors believe that the subclinical varicocele is an important cause of male infertility, others believe that the treatment of subclinical varicocele is not indicated. Subclinical varicoceles have been diagnosed with a variety of techniques, including Doppler studies, isotope scans, thermography, ultrasound and venography. The varying sensitivity of these different techniques probably explains why the reported incidence of subclinical varicocele varies from 12 to 75 per cent. 5 - 8 We documented the incidence of subclinical varicocele in a population of infertile men without clinical varicocele. We also report on the results of occlusion of subclinical varicoceles with regard to changes in seminal characteristics. MATERIALS AND METHODS
The 40 men who were referred to our clinic for evaluation of infertility had had abnormal seminal parameters on at least 2 semen analyses. Of the patients 26 consistently had sperm counts of less than 20 million per cc, including 13 who had sperm motility of less than 30 per cent. A total of 13 patients had initial sperm counts of greater than 20 million per cc but they had persistently poor motility (less than 30 per cent). A careful history revealed no obvious cause of the infertility. Serum follicle-stimulating hormone was normal in all patients. Routine physical examination of each patient included careful palpation of the scrotum with the patient standing, and with and without a Valsalva maneuver. None of the patients had evidence of a clinical varicocele. With their informed consent all patients underwent bilateral gonadal venography as outpatients. The procedure was performed transfemorally in 38 patients, while a transjugular approach was required in 2 whose right gonadal veins could not be catheterized via a transfemoral approach. To examine for a left scrotal varicocele, left renal venography was performed during a vigorous Valsalva maneuver with the patient in the supine position. Retrograde flow into the gonadal vein and scrotum was considered evidence of a varicocele. If a competent Accepted for publication November 8, 1988. Supported by the Veterans Administration.
valve was identified at the origin of the gonadal vein no further injections were performed. However, if a competent valve was seen proximal to the junction of the left gonadal and left renal veins the gonadal vein was catheterized, and a second injection was made during a Valsalva maneuver with the tip of the catheter just proximal to the competent valve. To examine for a right scrotal varicocele the right gonadal vein was entered and the catheter was advanced only several mm. to avoid bypassing a valve and erroneously diagnosing right subclinical varicocele. Venography then was performed during a vigorous Valsalva maneuver. If a competent valve was identified no further injections were performed. The anatomy of the varicocele and the ease of catheterization affected how occlusion of the internal spermatic vein was performed. In 19 patients multiple coil springs were deposited deep in the gonadal vein (fig. 1). In 2 patients multiple small veins originated from 1 major gonadal vein and we used boiling contrast medium for occlusion, while in 1 whose venous pattern precluded radiographic occlusion (fig. 2) we ligated the varicocele surgically through an inguinal approach. No complications occurred after either radiographic or surgical occlusion. Injections immediately afterwards showed occlusion of the vein to be complete in all patients. We did not perform late followup venograms to document the success of occlusion, since additional invasive tests could not be justified. After occlusion, all patients had followup appointments every 3 months. Semen analysis was performed at each visit. RESULTS
Of the 40 patients who underwent venography 22 (55 per cent) had a subclinical varicocele: 19 (86 per cent) on the left and 3 (14 per cent) on the right sides. No patient had bilateral subclinical varicocele. When the results were analyzed we first compared the patients with a subclinical varicocele to those with a normal venogram. The age and duration of infertility were similar in both groups. We then compared the pre-treatment sperm counts, motility and morphology in the 2 groups (table 1). With a Student t test no significant differences were found in any of the 3 parameters, indicating that the 2 groups were similar in composition (p >0.05). Of the 22 patients with a subclinical varicocele at least a 6month followup was available in 13. At least 2 semen analyses were performed after occlusion in each patient. The seminal
1372
1373
SUBCLINICAL SCROTAL VARICOCELES TABLE
1. Comparison of patients with and without a subclinical
varicocele before venography No. pts. Age Duration of infertility (yrs.) Sperm count (million/cc) Motility(%) Normal morphology(%)
TABLE 2.
Varicocele
No Varicocele
22 32.4 3.6 14.1 36.7 52.8
18 32.5 5.1 18.4 29.7 55.5
Comparison of mean seminal parameters before and after varicocele occlusion in 13 patients
Sperm number (million/cc) Motility(%) Normal morphology(%)
Pre-Treatment
After Occlusion
14.1 ± 3.9 36.7 ± 3.6 52.8 ± 2.4
20.2* ± 5.8 39.2 ± 4.4 55.9 ± 4.7
Mean ± standard error of mean.
* p <0.05 compared to pre-treatment number.
FIG. 1. A, scrotal varicocele with single internal spermatic vein. B, repeat injection after occlusion with coil springs.
less than 5 million per cc, the sperm count did not improve significantly after occlusion. DISCUSSION
FIG. 2. Internal spermatic veins originating near kidney, making occlusion impossible.
parameters of these 13 patients before and after varicocele correction were compared with paired t testing (table 2). In this analysis the pre-treatment counts, motility and morphology for each patient were averaged to determine a mean value for each parameter. Semen analyses after occlusion were averaged in a similar manner, and the mean values before and after treatment then were compared. There was a significant increase in sperm number after varicocele occlusion. No significant changes were noted in either sperm motility or morphology. Of the 13 patients 4 had an increase of more than 100 per cent in sperm number after varicocele occlusion. In patients who initially had a count of
Scrotal varicoceles were implicated in male infertility at least as long ago as 1889. 9 In 1965 MacLeod described the characteristic semen changes associated with varicoceles, that is decreased sperm count, decreased sperm motility and alteration in sperm morphology. 10 However, those changes are found in many patients who visit infertility clinics and are not peculiar to those with varicocele. In 1971 Dubin and Amelar reported on a large series of infertile men and found that clinical varicoceles occurred in 39 per cent. 2 Initial reports indicated that most clinical varicoceles occurred on the left side. In 1975 Dubin and Amelar reported on 504 varicocelectomies diagnosed by palpation alone. 11 Of these patients 86 per cent had a left varicocele, while bilateral varicocele was found in 14 per cent. By 1984, however, these numbers had changed dramatically. In a series of 870 varicocelectomies performed between 1980 and 1981 Amelar and Dubin found that 40 per cent were on the left and 4 per cent on the right sides, while 56 per cent of the patients had bilateral varicocele. 12 As in their previous study the diagnosis of a clinical varicocele was based solely on physical examination. It would appear that even in experienced hands the diagnosis of a clinical varicocele often is difficult. This high incidence of previously missed right varicoceles has been implicated in the failure of seminal characteristics to improve after unilateral left varicocelectomy.12 Numerous techniques have been used to aid in the diagnosis of a scrotal varicocele, including Doppler techniques, scrotal thermography, radionuclide scanning, scrotal ultrasound and gonadal venography. Although gonadal venography is considered the most accurate means of diagnosis, it is used only infrequently because it is invasive. 13 However, it has gained in popularity since the reports of successful radiographic occlusion of scrotal varicoceles-a varicocele currently can be diagnosed and corrected at the same time. The addition of the aforementioned diagnostic tools has resulted in an increase in the reported incidence of varicocele among infertile men. These diagnostic tools also have made the distinction between clinical and subclinical varicoceles less clear. In our series 48 per cent of the patients who appeared to be normal on physical examination had subclinical left varicocele, a figure in agreement with other recent reports. 6 · 7 However, the 7 per cent incidence of subclinical right varicocele in our group was much lower than the 44 to 62 per cent found in some other reports. 5 • 6 The difference probably is a function of the diagnostic tests used and the technical aspects of individual applications. The success of gonadal venography depends heavily on the technique of the radiologist but it generally is ac-
1374
YARBOROUGH, BURNS AND KELLER
cepted to be more sensitive than Doppler ultrasound or scrotal contact thermography in diagnosing a varicocele. 13 In a review of 42 autopsy specimens Nadel and associates found that the valve in the internal spermatic vein usually originated within 1 cm. of the origin of the vein. 14 If the angiographic catheter is placed too far into the internal spermatic vein the valve will be bypassed and a varicocele diagnosed incorrectly. That is especially important on the right side where the internal spermatic vein originates from the vena cava. Improper technique can readily explain the differences in the reported incidence of subclinical right varicoceles. · It generally has been accepted that occlusion or ligation of a clinical varicocele results in better seminal characteristics and a higher pregnancy rate than those in control subjects. 10• 11 • 15- 17 However, the criteria for improvement often were poorly defined and many of the reports failed to use a control group for comparison. Doubt recently has been cast on the efficacy of varicocele correction by failure of investigators to show significant improvement in either seminal characteristics or pregnancy rates. 13- 21 Vermeulen and associates showed not only that cumulative pregnancy rates were similar in treated and control groups but that no seminal characteristics had improved in patients who underwent varicocele correction and achieved pregnancy. 22 The role of the subclinical varicocele in male infertility is controversial. Previous investigators have reported improvement in seminal quality in approximately 50 per cent of the patients with corrected subclinical varicoceles. 3 •4 In our 13 patients with a minimum 6-month followup there was a significant increase in sperm number, with the average count increasing from 14.1 to 20.2 million per cc. Varicocele occlusion had no discernible effect on sperm motility or morphology. It should be emphasized that statistical improvement does not always constitute clinical improvement. Increasing the average sperm number from 14.1 to 20.2 million per cc may have no meaningful effect on pregnancy rates. Pregnancy rates of 32 to 50 per cent have been reported after occlusion or surgical ligation of subclinical varicoceles. 7 • 23 To date only 1 couple in our series has become pregnant and that pregnancy resulted in a miscarriage. Because we treated all patients with subclinical varicoceles we do not have an untreated control group for comparison; lack of such a control group will make it impossible for us to determine whether correction of subclinical varicoceles results in an increase in the pregnancy rate. Even if a control group was present interpretation would remain difficult, since in many of our patients the spouse also is being treated concurrently for infertility. We also should note that this study only looks at sperm number, motility and morphology. Newer tests, such as the sperm penetration assay, might be useful to evaluate the benefit of correction of subclinical varicoceles. This assay has proved to be useful to define the role of varicocele correction in patients with a clinical varicocele. 24 Burke recently reported that although the normally measured characteristics of sperm number, motility and morphology did not change after varicocele correction, there was a significant increase in sperm velocity. 25 This may have a beneficial effect on pregnancy rates. We conclude that approximately 55 per cent of all infertile men with no evidence of a clinical varicocele will have a subclinical varicocele documented with venography. In our small group of patients varicocele occlusion resulted in a small but statistically significant increase in sperm number. The effect of this increase on pregnancy rate is unknown. A patient occasionally will have a substantial increase in sperm count after occlusion. In the patient who does not have a clinically apparent varicocele and who has failed to improve on conventional medical therapy gonadal venography could be considered.
However, the patient should be made aware that occlusion of the subclinical varicocele may not enhance the chances of fertility. REFERENCES
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