BERKELEY, CA (UroToday Inc.) - Varicocele remains the most common correctable etiologic factor in the management of infertility. The incidence of abnormal semen parameters is greater in patients who have varicocele with infertility than in comparable controls. This highlights the possible etiologic role of varicocele in the alteration of semen quality. Traditionally, varicoceles have been treated by surgical interruption above the pampiniform plexus at varying levels. This can be done surgically either through an open or laparoscopic technique. Better anatomic delineation by venography identifies additional veins that may be missed surgically, and this imaging minimizes the possibility of future recurrences during subsequent embolization. This technique showed a high technical failure rate in previous series, perhaps reflecting a learning curve. In their recent publication in the February 2004 issue of Urology, Dr. Nabi and colleagues in the Department of Surgery at the University of Aberdeen, Scotland report their results in 71 patients who underwent retrograde varicocele embolization for fertility reasons.

Seventy-one patients with infertility as an indication for venous embolization were identified. Partners of these patients were pre-evaluated in an infertility clinic and all evaluations were normal. The mean age of the partners of these patients was 28.6 years. All patients underwent a pre-embolization workup to include physical examination, Doppler ultrasonography of the scrotum and the grading of the varicocele. The testicular volume was measured and the patients had at least two pre-embolization semen analyses. Semen analysis was carried out using the World Health Organization criteria. At least one of the parameters off their semen analyses was abnormal prior to embolization.

All patients underwent embolization under local anesthesia by a single radiologist. Access was obtained by the right common femoral vein. Following left renal venography, the left spermatic vein was then catheterized and embolized by thrombogenic coil. All patients underwent 2 hours of bed rest following the procedure. Post-embolization semen tests were made at 3 and 6 months and if there were no improvements, subsequent semen analysis were obtained at 9 and 12 months. Also, patients were divided into two groups on the basis of whether they achieved a successful pregnancy on follow-up.

In 68 patients (96%), the procedure was technically successful. Failure in 3 patients was due to venous spasm, the presence of extensive collaterals, and failure to localize the testicular vein on that side. Nineteen patients (26%) had various anomalous vessels on venography.

An improvement in semen parameters in terms of semen density, morphology and motility occurred, but statistically significant improvement was only seen in the motility and morphology parameters in patients with a pretreatment semen density between 10 and 30 million/mL. Fifty-one patients replied to a follow-up questionnaire.

Five patients who failed to achieve pregnancy chose assisted reproductive techniques and were excluded from the analysis. One additional patient had a varicocele recurrence and underwent open inguinal surgical ligation and was excluded from the analysis.

Of the 45 remaining patients, 18 (40%) had a successful pregnancy at a mean follow-up of 3.6 years. None of theses patients had tried any other method to reproduce after embolization. The quality of semen in the 18 patients with a successful pregnancy was compared with that of the 27 who failed to achieve pregnancy. Although improvement in the semen quality occurred in both groups after embolization, a statistically significant difference in semen quality was not seen. No other parameter, including the presence of anomalous vessels on venography, testicular size, or varicocele size, had a statistical significance.

This study demonstrates that retrograde embolization of varicocele in experienced hands improves semen parameters, especially in patients with a pre-embolizaiton semen density of 10 to 30 million/mL. No correlation, however, was found between an improvement in semen quality and pregnancy rate.

Urology 2004;63:359-363.