Varicocelectomy response rate: Pregnancy predictor

San Francisco-Men who respond quickly to varicocele repair have a better chance of fathering children than men who take longer to respond do. That's the clinical pearl from an early study of infertile men at the Medical College of Wisconsin, Milwaukee, reported at the American Society for Reproductive Medicine annual meeting.

"This finding is based on clinical experience," Anand Shridharani, MD, a urology resident working with Jay Sandlow, MD, told Urology Times.

"What we saw in practice was that men whose semen parameters improve earlier achieve pregnancy more frequently than those who improve later or do not improve at all. We crunched the numbers to prove this finding."

Surgical varicocelectomy improves semen parameters in between 60% and 70% of men, yielding pregnancy rates of up to 50%. However, few data identify prognostic factors for successful pregnancy following varix ligation.

Drs. Shridharani and Sandlow conducted a retrospective study of 144 men with clinically palpable varicoceles who underwent microsurgical subinguinal varicocele repair between September 2003 and November 2007. Their goal was to compare pregnancy rates among couples in which the man showed improvement in at least one semen parameter within 3 months of surgery with those couples in which the man took longer to respond.

"In the couples where the man improved at 3 months, about 70% got pregnant," Dr. Shridharani said. "The number of couples who got pregnant was lower for men who improved at 6 months or longer after surgery. The bottom line is that if your semen parameters improve at 3 months, you are much more likely to get pregnant."

Men in the study had a semen analysis before surgery and at 3-month intervals following surgical repair of the varicocele. Of the 144 couples represented in the retrospective chart review, 117 couples had semen analysis data, 70 couples had pregnancy data, and 56 couples had both semen analysis and pregnancy data.

Semen parameters measured included a 50% or greater increase in concentration, motility, or total progressively motile/ejaculate as measured at 3 months compared to 6 months or later. Pregnancy could be achieved by natural means or by intrauterine insemination (IUI), but not by in vitro fertilization.

Overall, semen parameters improved in 62% (73/117) of men and 49% of couples (34/70) achieved pregnancy by natural means or IUI within 12 months following surgery. But among couples who became pregnant, 84% of men showed improvement in semen parameters at 3 months compared with 10% of those with improved semen parameters at 6 months or later and 6% who showed no improvement in semen parameters 12 months postoperatively.

Among couples in which the man showed improved semen parameters at 3 months, 68% became pregnant. Among couples who did not become pregnant, 50% had improved semen parameters at 3 months, 8% showed improvement at 6 months, and 44% showed no improvement in semen parameters at 12 months after varicocele repair.

"If semen parameters have not improved at 6 months, we can suggest that couples might want to look seriously at assisted reproductive technologies, especially in the setting of advanced maternal age," Dr. Shridharani said.

"We hope this study offers information that clinicians can use in preoperative and postoperative counseling. If these results are reproducible in larger numbers of patients, we may make more inferences based on the numbers. Ultimately, offering this information to patients will allow them to make better decisions about seeking further treatment after varicocele repair and to improve their allocation of resources."