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. 2023 Jan;41(1):164-197.
doi: 10.5534/wjmh.220048. Epub 2022 Jun 13.

Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

Rupin Shah  1 , Ashok Agarwal  2 , Parviz Kavoussi  3 , Amarnath Rambhatla  4 , Ramadan Saleh  5 , Rossella Cannarella  6 , Ahmed M Harraz  7   8   9 , Florence Boitrelle  10   11 , Shinnosuke Kuroda  12 , Taha Abo-Almagd Abdel-Meguid Hamoda  13   14 , Armand Zini  15 , Edmund Ko  16 , Gokhan Calik  17 , Tuncay Toprak  18 , Hussein Kandil  19 , Murat Gül  20 , Mustafa Emre Bakırcıoğlu  21 , Neel Parekh  22 , Giorgio Ivan Russo  23 , Nicholas Tadros  24 , Ates Kadioglu  25 , Mohamed Arafa  12   26   27 , Eric Chung  28 , Osvaldo Rajmil  29 , Fotios Dimitriadis  30 , Vineet Malhotra  31 , Gianmaria Salvio  32 , Ralf Henkel  33   34 , Tan V Le  35   36 , Emrullah Sogutdelen  37 , Sarah Vij  22 , Abdullah Alarbid  8 , Ahmet Gudeloglu  38 , Akira Tsujimura  39 , Aldo E Calogero  6 , Amr El Meliegy  40 , Andrea Crafa  6 , Arif Kalkanli  41 , Aykut Baser  42 , Berk Hazir  43 , Carlo Giulioni  44 , Chak-Lam Cho  45 , Christopher C K Ho  46 , Ciro Salzano  47 , Daniel Suslik Zylbersztejn  48 , Dung Mai Ba Tien  35 , Edoardo Pescatori  49 , Edson Borges  50 , Ege Can Serefoglu  51 , Emine Saïs-Hamza  10   11 , Eric Huyghe  52 , Erman Ceyhan  53 , Ettore Caroppo  54 , Fabrizio Castiglioni  55 , Fahmi Bahar  56 , Fatih Gokalp  57 , Francesco Lombardo  58 , Franco Gadda  59 , Gede Wirya Kusuma Duarsa  60 , Germar-Michael Pinggera  61 , Gian Maria Busetto  62 , Giancarlo Balercia  32 , Gianmartin Cito  63 , Gideon Blecher  64   65 , Giorgio Franco  66 , Giovanni Liguori  67 , Haitham Elbardisi  26   68 , Hakan Keskin  38 , Haocheng Lin  69 , Hisanori Taniguchi  70 , Hyun Jun Park  71   72 , Imad Ziouziou  73 , Jean de la Rosette  74 , Jim Hotaling  75 , Jonathan Ramsay  76 , Juan Manuel Corral Molina  77 , Ka Lun Lo  78 , Kadir Bocu  79 , Kareim Khalafalla  26   80 , Kasonde Bowa  81 , Keisuke Okada  82 , Koichi Nagao  83 , Koji Chiba  82 , Lukman Hakim  84 , Konstantinos Makarounis  85 , Marah Hehemann  86 , Marcelo Rodriguez Peña  87 , Marco Falcone  88 , Marion Bendayan  10   11 , Marlon Martinez  89 , Massimiliano Timpano  88 , Mesut Altan  90 , Mikkel Fode  91   92 , Mohamed S Al-Marhoon  93 , Mohammad Ali Sadighi Gilani  94 , Mohammad Ayodhia Soebadi  95 , Nazim Gherabi  96 , Nikolaos Sofikitis  97 , Oğuzhan Kahraman  53 , Ponco Birowo  98 , Priyank Kothari  99 , Puneet Sindhwani  100 , Qaisar Javed  101 , Rafael F Ambar  102   103 , Raghavender Kosgi  104 , Ramy Abou Ghayda  105 , Ricky Adriansjah  106 , Rosita Angela Condorelli  6 , Sandro La Vignera  6 , Sava Micic  107 , Shannon Hee Kyung Kim  108   109 , Shinichiro Fukuhara  110 , Sun Tae Ahn  111 , Taymour Mostafa  40 , Teng Aik Ong  112 , Teppei Takeshima  113 , Toshiyasu Amano  114 , Trenton Barrett  115 , Umut Arslan  18 , Vilvapathy Senguttuvan Karthikeyan  116 , Widi Atmoko  104 , Yasushi Yumura  113 , Yiming Yuan  117 , Yuki Kato  118 , Davor Jezek  119 , Bryan Kwun-Chung Cheng  120 , Georgios Hatzichristodoulou  121 , Jun Dy  122 , Eduard Ruiz Castañé  123 , Ahmed I El-Sakka  124 , Quang Nguyen  125   126 , Selcuk Sarikaya  127 , Luca Boeri  59 , Ronny Tan  128   129 , Mohamad A Moussa  130   131 , Ahmed El-Assmy  7 , Hamed Alali  132 , Naif Alhathal  133 , Yasser Osman  7 , Dragoljub Perovic  134 , Hesamoddin Sajadi  99 , Hamed Akhavizadegan  135 , Miroslav Vučinić  136 , Said Kattan  133 , Mohamed S Kattan  133 , Nasser Mogharabian  137 , Nguyen Ho Vinh Phuoc  35 , Kay Seong Ngoo  138 , Mohammad H Alkandari  139 , Shaheed Alsuhaibani  140 , Ioannis Sokolakis  121 , Mehdi Babaei  141 , Mak Siu King  78 , Thorsten Diemer  142 , Marcelo M Gava  102   103 , Raphael Henrique  143 , Rodrigo Spinola E Silva  102   103 , Gustavo Marquesine Paul  144 , Tiago Cesar Mierzwa  145 , Sidney Glina  102 , Kashif Siddiqi  146 , Han Wu  147 , Jana Wurzacher  148 , Ala'a Farkouh  12 , Hwancheol Son  149 , Suks Minhas  150 , Joe Lee  151 , Nikko Magsanoc  152 , Paolo Capogrosso  153 , German Jose Albano  89 , Sheena E M Lewis  154 , Channa N Jayasena  155   156 , Juan G Alvarez  157 , Colin Teo  158 , Ryan P Smith  159 , Jo Ben M Chua  160 , Christian Fuglesang S Jensen  161 , Sijo Parekattil  162 , Renata Finelli  12 , Damayanthi Durairajanayagam  163 , Keshab Kumar Karna  12 , Abdelkareem Ahmed  9 , Don Evenson  164 , Yukihiro Umemoto  165 , Ana Puigvert  166 , Gökhan Çeker  167   168 , Giovanni M Colpi  169 ; Global Andrology Forum
Affiliations

Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

Rupin Shah et al. World J Mens Health. 2023 Jan.

Abstract

Purpose: Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility.

Materials and methods: Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field.

Results: The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available.

Conclusions: This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

Keywords: Consensus; Disease management; Male infertility; Survey; Varicocele.

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Conflict of interest statement

The authors have nothing to disclose.

Figures

Fig. 1
Fig. 1. Geographical distribution of respondents. The number of respondents is shown in brackets after the name of each country. The violet color indicates the country with the greatest number of respondents (n=105), the blue color are those with a lower number (n=59), the orange color are those with a further reduction in the number of respondents (from 26 to 38), and the yellow color are the countries with the lowest number of respondents (from 1 to 17).
Fig. 2
Fig. 2. Number of varicocele repairs (VRs) done annually by the respondents.
Fig. 3
Fig. 3. Degree of agreement of the respondents with the premise of the survey.
Fig. 4
Fig. 4. Estimated percentage of patients presenting with common symptoms related to varicocele.
Fig. 5
Fig. 5. Therapeutic decisions on the management of a couple with primary infertility and clinical varicocele. OAT: oligoasthenoteratozoospermia, ART: assisted reproductive technology, IUI: intrauterine insemination, IVF: in vitro fertilization, ICSI: intracytoplasmic sperm injection.
Fig. 6
Fig. 6. Therapeutic decisions on the management of a couple with secondary infertility and clinical varicocele. OAT: oligoasthenoteratozoospermia, ART: assisted reproductive technology, IUI: intrauterine insemination, IVF: in vitro fertilization, ICSI: intracytoplasmic sperm injection.
Fig. 7
Fig. 7. Choice of varicocele repair technique.
Fig. 8
Fig. 8. Frequency of complications after varicocele repair.
Fig. 9
Fig. 9. Chances of clinically significant improvement in semen parameters after varicocele repair.
Fig. 10
Fig. 10. Chances of spontaneous pregnancy after varicocele repair.
Fig. 11
Fig. 11. Frequency of varicocele repair in a man with NOA. NOA: non-obstructive azoospermia.
Fig. 12
Fig. 12. Management of patients with clinical varicocele and NOA. NOA: non-obstructive azoospermia, TESE: testicular sperm extraction, ICSI: intracytoplasmic sperm injection.
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