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

Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations
Authors: Shah R, Agarwal A, Kavoussi P, et al, World J Men’s Health Published 2023 Jan 41(1): 164-197
https://doi.org/10.5534/wjmh.220048

Preamble:
Varicocele and male infertility: a never-ending story!
Varicocele affects nearly 15% of the general male population and is diagnosed in 19% to 41% of primary male infertility and 80% of secondary male infertility cases. Varicocele is also considered the most common correctable cause of male infertility. However, the management of varicocele for fertility and non-fertility related indications is not clearly established and many areas of controversy remain. Current challenges in the management of infertile men
with varicocele include: 1) determining the true benefit of varicocele repair (VR) on seminal parameters, reproductive hormone levels, pregnancy and live birth rates; 2) predictive factors of the outcome of VR in infertile men; 3) the role of VR in the management of infertile men with varicocele and azoospermia or in those with subclinical varicocele; and the management of infertile men with varicocele recurrence.

In fact, considerable variation and controversy is expected in the worldwide practice patterns of varicocele management for different clinical situations.

Therefore, the aim of this study was to use a comprehensive online survey to determine the attitudes and practice patterns of clinicians worldwide in the management of varicocele in infertile men, thus identifying divergence and concurrence in global practice patterns, and to compare these with the latest international (American Urological Association/American Society for Reproductive Medicine [AUA/ASRM], European Association of Urology [EAU])
practice guidelines, and with evidence from systematic reviews and recent meta-analyses. Finally, to provide further clarity in each area of varicocele evaluation and management, an “Expert Opinion” has been provided based on the consensus of 16 highly experienced experts. This unique project lasted for 12 months and witnessed enormous contributions from 185 authors belonging to 40 countries.

Capsule:
The questionnaire used for this survey has been created from questions raised by a large, international group of clinicians, and thus reflects the real-life, practical concerns of physicians dealing with male infertility and varicocele. The survey responses represent the opinions and practices of 574 clinicians from 59 countries and reveal a marked diversity in all aspects of varicocele management. The survey highlights several areas where there is inconclusive data and the need for more research, and identifies numerous lacunae in the management guidelines issued by professional bodies (EAU, AUA, ASRM), which need to be addressed in future guidelines. Besides, this survey serves the useful purpose of allowing clinicians to compare their practices with those of their peers, and against recommended guidelines and the latest research findings, and thus rethink some of their own practices and clinical protocols.

Recommendation:
Clinicians dealing with varicocele and male infertility are invited to ponder over what they know, what they do, where they go wrong, and what they should do.

Acknowledgment: Ramadan Saleh, MD helped with this news item.