1. Insight’12 – Lite, Coimbatore, India – May 2012
Sandro Esteves, MD, PhD
Director, ANDROFERT
Center for Male Reproduction and Infertility
Campinas, BRAZIL

2. Varicocee Varicocele: Prevalence
• 15% male population
• 35% of male infertility cases
Esteves, 2

3. Varicocele: Physical
Examination
Esteves, 3

4. Varicocele: Use of Pencil-
probe Doppler
Esteves, 4

5. Courtesy of Prof. Juan Alvarez
Varicocele:
Pathophysiology
Epididymis
Spermatogonia
Seminiferous
Tubules
Spermatocytes
Vas
Deferens Early
spermatids
Sertoli Elongated
Cell spermatids
Mature
spermatozoa
ROS-induced DNA damage
Alvarez and Sakkas, Fertil Steril, 2010

6. Varicocele: Treatment
Surgical
Treatment
• Indication for Treatment:
Clinical (palpable) varicocele
and
Abnormal semen analysis
results
Esteves, 6

7. Surgical Treatment of Varicocele
Technique Internal External Recurrence Hydrocele Spontaneous
Spermatic Spermatic Rate Formation Pregnancy
Vein Vein Rate Rate
Ligation Ligation
Retroperitoneal Yes No 7-35% 6-10% 25-55%
High-Ligation
(Palomo)
Laparoscopic Yes No 2-7% 0-9% 14-42%
Embolization Yes No 2-24% NR 20-40%
Macroscopic Yes Yes 0-37% 7% 34-39%
Inguinal
(Ivanissevich)
Microscopic Yes Yes 0-0.3% 0-1.6% 33-56%
Inguinal or
Subinguinal45,51,54,55
Esteves, 7

8. Miyaoka & Esteves. Critical appraisal on the role of varicocele in male infertility.
Esteves, 8
Adv Urol 2012; Epub

9. Surgical Treatment of Varicocele
Fertility
Restoration
Spontaneous
Pregnancy
Esteves, 9

10. Varicocelectomy for Fertility Restoration
Fertil Steril 2007;88:639–48.
Esteves, 10

11. Implications for Practice
• Varicocele treatment
Surgical
Treatment
• Effect
• Decrease seminal oxidative stress
• Improve sperm DNA integrity
• Improve semen parameters
• Increase the likelihood of
spontaneous and assisted pregnancy
Esteves, 11

12. Surgical Treatment of Varicocele
• It can improve success of ART
Fertility
Improvement
Fertility ICSI
Restoration Outcomes
Spontaneous
Pregnancy Fertility
Improvement
Sperm Retrieval in
Azoospermia
Esteves, 12

13. Varicocele Repair Before ICSI
Clinical Outcome of Intracytoplasmic Sperm Injection in Infertile
Men With Treated and Untreated Clinical Varicocele
SC Esteves, FV Oliveira, RP Bertolla. ANDROFERT, Center for Male
Reproduction, Campinas, BRAZIL and Division of Urology, São Paulo Federal
University, São Paulo, BRAZIL.
The Journal of Urology Vol. 184,1442-1446, October 2010
Total Number of Motile
Microsurgical Sperm (x106)
varicocele repair prior
15.4
to ICSI (N=80) P<0.01
6.7
ICSI in the presence of
varicocele (N=162)
Esteves, 13 Pre-op Post-op

14. Varicocele and ICSI Outcomes
Treated Varicocele Untreated Varicocele
78%*
66% *P<0.05
46%*
31% 31%
22%
Fertilized Eggs Live Birth (%) Miscarriage (%)
(%2PN)
Odds ratio 1.87 0.43
95% CI 1.08 - 3.25 0.22 – 0.84
P-value 0.03 0.01
Esteves SC, Oliveira FV, Bertolla RP. Clinical Outcome of ICSI in Infertile Men with
Esteves, 14
Treated and Untreated Clinical Varicocele. J Urol 2010;184:1442-1446

15. Varicocele Repair Before Sperm Retrieval
Sperm Retrieval and Intracytoplasmic Sperm Injection in
Men With Nonobstructive Azoospermia, and Treated and
Untreated Varicocele
K Inci, M Hascicek, O Kara et al. Department of Urology, School of
Medicine, Hacettepe University, Ankara, Turkey.
The Journal of Urology Vol. 182,1500-1505, October 2009
Successful Sperm Retrieval
Microsurgical
Rate
varicocele repair prior
to sperm retrieval ICSI OR: 2.63 (95% CI: 1.05-6.60; P=0.03)
(N=66) 53%
30%
Sperm Retrieval in the
presence of varicocele
(N=30) Treated Varicocele
Esteves, 15 Untreated Varicocele

16. Take-home Messages
Evidence for a Positive Impact in
the Surgical Treatment of Clinical
Varicoceles :
1. Increase the likelihood of spontaneous
conception in men with mild/moderate
abnormal semen parameters.
2. Increase the odds of live birth in subgroups
of men with severe oligozoospermia
undergoing ICSI.
3. Increase the chance of having a successful
sperm retrieval in the subgroup of patients
with non-obstructive azoospermia.
Esteves, 16