Outcome of varicocelectomy on different degrees of total motile sperm count: A systematic review and meta-analysis

Figures & data

Table 1. Selection criteria of included studies.

	Included	Excluded
Population	Infertile men with clinical varicocele	Azoospermia Subclinical varicocele Other potential risk factors that may impair TMSC Children or adolescents Fertile men with varicocele
Intervention	Microsurgical, open, or lapro-endoscopic surgical ligation	No adjuvant medicines treatment
Comparison	The change of TMSC over time	Semen parameters that were described in terms of counts, concentration, or motility
Outcomes	TMSC before and after varicocelectomy or pregnancy	Spouse’s fertility status not described
Study type	Any type

Table 2. Characteristics of included studies.

Author (year)	Design	Patients	Varicocele grade	Surgical approach	follow-up (month)	TMSC (million)	Outcomes included
Dubin 2018	Interventional trials	Infertile patients	Any grade (I II III)	Subinguinal approach microsurgical varicocele	6	<2	TMSC before and after varicocelectomy
Masterson et al. 2018	Retrospective data analyses	Infertile patients	Any grade (I II III)	Subinguinal approach microsurgical varicocele	>6	<5	TMSC before and after varicocelectomy, SP
Samplaski et al. 2017	Interventional trials	Infertile patients	Palpable varicocele and ultrasound confirmed	Subinguinal approach microsurgical varicocele	>6	>9, 5–9, < 5	TMSC before and after varicocelectomy
Fukuda et al. 2015	Interventional trials	Infertile patients	Palpable varicocele and ultrasound confirmed	Subinguinal approach microsurgical varicocele	12	<3, 3–9,>9	TMSC before and after varicocelectomy
Jallouli et al. 2008	Retrospective data analyses	Infertile patients	Palpable varicocele and ultrasound confirmed	Ppeninguinal approach and laparoscopically	12	<1.5,1.5–5, >5	TMSC before and after varicocelectomy, SP
Gui 2006	Retrospective data analyses	Infertile patients	Clinical varicocele	High inguinal approach	12–24	<5, 5–20, >20	SP
Matkov 2001	Retrospective data analyses	Infertile patients	Clinical varicocele	Open inguinal/subinguinal approach and laparoscopically	>12	<5, 5–20, >20	SP
Takeuchi et al. 2014	Retrospective data analyses	Infertile patients	Clinical varicocele grade II or III	Microsurgical varicocelectomy	12	<5	TMSC before and after varicocelectomy, SP
Cayan 2002	Retrospective data analyses	Infertile patients	Palpable varicocele	Microsurgical varicocelectomy	>12	<1.5,1.5–5,5–20,>20	SP

TMSC: total motile sperm count; SP: spontaneous pregnancy

Figure 1. Flow diagram of literature search. Ninety-six articles were initially identified. On screening, among these articles, abstracts of 16 potential articles were browsed based on the outcomes in terms of sperm parameters, nine articles include six interventional trials and three retrospective data analysis that were included. Main reasons of exclusion were: trials were not comparison of TMSC but other sperm parameters (motility and concentration).

Figure 2. Impact of varicocelectomy on total motile sperm count. Mean TMSC classified as: <2 million – profound; 2–5 million – severe; 5–10 million – moderate; >10 million – mild. The improvement in TMSC was 10.20 million (95% CI: 9.11–11.30, p < 0.0001) in profound group, 15.77 million (95% CI: 10.65–20.89, p < 0.0001) in severe group, 19.18 million (95% CI: 10.40–27.96, p < 0.0001) in moderate group, and 49.68 million (95% CI: 38.74–60.62, p < 0.0001) in mild group post-varicocelectomy.

Table 3. Pregnancy rates following varicocelectomy.

TMSC (million)	N/Total N SP rate (%)	Mean age ±SD (range)	Female fertility	follow-up
<1.5
Cayan 2002	21/132 (15.9)	29.5 ± 5.9	Excluded history of gynecologic surgery or ovultory abnormalities	24
Jallouli et al. 2008	10/62 (16.1)	34.7 (20–50)	No advanced female factors	12
Overall	31/194 (16.0)
<5
Matkov 2001	4/20 (20.0)	NA	No female factors referral for IVF.	12
Cayan 2002	19/62 (30.6)	29.5 ± 5.9	Excluded history of gynecologic surgery or ovulatory abnormalities	24
Jallouli et al. 2008	9/22 (40.9)	34.7 (20–50)	No advanced female factors	12
Gui 2006	4/33 (12.1)	25.6 (20–36)	Excluded history of gynecologic surgery or ovulatory abnormalities	12–24
Overall	36/137 (26.3)
5–20
Matkov 2001	7/20 (35.0)	NA	No female factors referral for IVF.	12
Cayan 2002	48/126 (38.0)	29.5 ± 5.9		24
Jallouli et al. 2008	39/59 (66.1)	34.7 (20–50)	No advanced female factors	12
Gui 2006	14/33 (42.4)	25.6 (20–36)	Excluded history of gynecologic surgery or ovulatory abnormalities	12–24
Overall	108/238 (45.4)
>20
Matkov 2001	4/18 (22.2)	NA	No female factors referral for IVF.	12
Cayan 2002	75/125 (60.0)	29.5 ± 5.9	Excluded history of gynecologic surgery or ovulatory abnormalities	24
Gui 2006	18/32 (56.3)	25.6 (20–36)	Excluded history of gynecologic surgery or ovulatory abnormalities	12–24
Overall	97/175 (55.4)

TMSC: total motile sperm count; NA: not available; SD: standard deviation; SP: spontaneous pregnancy. After varicocelectomy, the SP rate was highest at 55.4% in the TMSC > 20 million group, followed by 45.4% in the TMSC 5–20 million group, and 26.3% in the TMSC < 5 million group. While the TMSC < 1.5 million group demonstrated the lowest SP rate of only 16.0%

Dubin JM, Greer AB, Kohn TP, Masterson TA, Ji L, Ramasamy R. 2018. Men with severe oligospermia appear to benefit from varicocele repair: a cost-effectiveness analysis of assisted reproductive technology. Urology. 111:99–103.

 PubMed Web of Science ®Google Scholar

Masterson TA, Greer AB, Ramasamy R. 2018. Time to improvement in semen parameters after microsurgical varicocelectomy in men with severe oligospermia. Can Urol Assoc J.

 Web of Science ®Google Scholar

Samplaski MK, Lo KC, Grober ED, Zini A, Jarvi KA. 2017. Varicocelectomy to “upgrade” semen quality to allow couples to use less invasive forms of assisted reproductive technology. Fertil Steril. 108(4):609–612.

 PubMed Web of Science ®Google Scholar

Fukuda T, Miyake H, Enatsu N, Matsushita K, Fujisawa M. 2015. Assessment of time-dependent changes in semen parameters in infertile men after microsurgical varicocelectomy. Urology. 86(1):48–51.

 PubMed Web of Science ®Google Scholar

Jallouli H, Hadj Slimen M, Sahnoun A, Kechou S, Ben Amar S, Bahloul A, Mhiri MN. 2008. [Surgical treatment of varicocele improves fertility and facilitates medically assisted procreation]. Prog Urol. 18(8):543–549.

 PubMed Web of Science ®Google Scholar

Gui X, Chen J, Sun X, Wen R, Chen R, Zheng J, Zhang C. 2006. The value of pre-operative semen analysis as a restore index of fertilizing capacity after varicocelectomy. Zhonghua Nan Ke Xue. 12(2):145–147.

 PubMedGoogle Scholar

Matkov TG, Zenni M, Sandlow J. 2001. Preoperative semen analysis as a predictor of seminal improvement following varicocelectomy. Fertil Steril. 75:63–68.

 PubMed Web of Science ®Google Scholar

Takeuchi T, Nagao K, Aono N, Mori Y, Nakajo Y, Okuda T, Kyono K. 2014. Beneficial effect of microsurgical varicocelectomy on semen parameters and clinical outcome in severe male factor infertility. Fertil Steril. 102:3.

 PubMed Web of Science ®Google Scholar

Çayan S, Erdemir F, Özbey I, Turek PJ, Kadioğlu A, Tellaloğlu S. 2002. Can varicocelectomy significantly change the way couples use assisted reproductive technologies? J Urol. 167(4):1749–1752.

 PubMed Web of Science ®Google Scholar