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The Argument for Varicocele Repair in Nonobstructive Azoospermia

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Emerging Topics in Reproduction

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Abstract

Nonobstructive azoospermia (NOA) is a severe form of male factor infertility that typically obligates couples to intracytoplasmic sperm injection (ICSI) with testicular sperm. A significant proportion of these men, however, will also present with a palpable varicocele—a known modifiable risk factor for subfertility. In this review, we will discuss the current evidence that supports the use of varicocele repair in men with nonobstructive azoospermia. Numerous observational noncontrolled studies, substantiated by meta-analyses, now link varicocele repair in return of viable sperm adequate for in vitro fertilization (IVF) with ICSI to the ejaculate, rare unassisted pregnancy, increased testicular sperm retrieval rates, and improved pregnancy outcomes with intracytoplasmic sperm injection. Due to suboptimal study design, these inferred benefits must be met with caution. In this regard, active controversy remains over the efficacy of varicocele repair in men with NOA. Additionally, concerns continue regarding cost-effectiveness, the addition of surgical morbidity, and delays to testicular sperm extraction. We carefully review the data and analysis supporting these counter arguments against varix repair. Finally, alternative indications for varicocelectomy in the NOA population are briefly discussed, representing a set of therapeutic criteria that may settle the decision to treat or to observe.

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Abbreviations

ART:

Assisted reproductive technologies

FSH:

Follicle-stimulating hormone

ICSI:

Intracytoplasmic sperm injection

IVF:

In vitro fertilization

microTESE:

Microsurgical testicular sperm extraction

NOA:

Nonobstructive azoospermia

SRR:

Sperm retrieval rate

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Authors and Affiliations

  1. Department of Urology, University of British Columbia, Vancouver, BC, Canada

    Connor M. Forbes MD

  2. Department of Urology, Weill Cornell Medicine, New York, NY, USA

    Russell P. Hayden MD & Marc Goldstein MD, DSc(hon), FACS

  3. Department of Male Reproductive Medicine and Surgery, Weill Cornell Medicine - New York Presbyterian Hospital, New York, NY, USA

    Marc Goldstein MD, DSc(hon), FACS

Authors
  1. Connor M. Forbes MD
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  2. Russell P. Hayden MD
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  3. Marc Goldstein MD, DSc(hon), FACS
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Corresponding author

Correspondence to Marc Goldstein MD, DSc(hon), FACS .

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Editors and Affiliations

  1. Division of Andrology, University of Utah School of Medicine, Salt Lake City, Utah, USA

    Douglas T. Carrell

  2. Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Catherine Racowsky

  3. Department of Urology, Weill Cornell Medical College, New York, New York, USA

    Peter N. Schlegel

  4. NICHD, National Institutes of Health, Bethesda, Maryland, USA

    Alan H. DeCherney

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Forbes, C.M., Hayden, R.P., Goldstein, M. (2018). The Argument for Varicocele Repair in Nonobstructive Azoospermia. In: Carrell, D., Racowsky, C., Schlegel, P., DeCherney, A. (eds) Emerging Topics in Reproduction. Springer, Cham. https://doi.org/10.1007/978-3-319-90823-6_2

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