Future and Controversies
In 1992, researchers introduced a new
micromanipulation technique known as intracytoplasmic sperm injection (ICSI).
With ICSI, surgeons inject a single spermatozoon into an oocyte to initiate fertilization
and, eventually, a pregnancy. With the success of this technique, some
researchers question the need for varicocele repair.
Conversely, a cost-analysis study by Schlegel
shows the significant cost advantage of varicocele repair over ICSI. In addition, varicocele
repair has the potential for improving the male factor, rather than using
unknown sperm. ICSI also involves in vitro fertilization (IVF), which carries
some risk for the female who donates surgically removed eggs.
Another current topic focuses on the benefit
of varicocele repair in men who are azoospermic or severely oligospermic.
Although numerous studies indicate that varicocele repair can improve
spermatogenesis in up to one third of azoospermic men, the initiation of
spontaneous pregnancy is highly unusual in this population. The remaining two
thirds eventually require testicular sperm extraction and IVF-ICSI, even after
varicocele repair. Couples must therefore be counseled realistically regarding
the benefit of varicocelectomy in this setting.
Other concerns focus on the benefit of
varicocele repair in infertile men with poor semen quality who have only
ultrasound evidence of a varicocele. While opinions differ about the value of
repairing subclinical varicoceles in infertile men, most experts do not
recommend it.
