VARICOCELE  Most common identifiable pathology in infertile men.  Affects 35% - 40% of men presenting for infertility evaluation.

 Management of male-factor infertility with clinical varicocele and abnormal semen parameters: Varicocele repair Assisted Reproductive Technologies (ARTs) ○ Intrauterine Insemination (IUI) ○ In Vitro Fertilization with Intracytoplasmic Sperm Injection (IVF/ICSI) Observation

OBJECTIVES  Assess pregnancy outcomes of two cohorts of infertile men with bilateral varicoceles: Bilateral varicocelectomy No surgery

 Retrospective review of 610 consecutive infertile couples with clinical varicoceles.  All men had: one year or more of infertility bilateral clinically palpable varicocele (examined by same investigator – AZ) abnormal semen parameters  Couples with subclinical or unilateral clinical varicoceles, tubal obstruction or ovulatory failure excluded.

 Couples counseled about treatment options (observation, varicocelectomy & ARTs)  All microsurgical varicocelectomies performed by same surgeon (AZ).

 Outcome measures: Pregnancy rates (natural and assisted) Changes in semen parameters Utilization of ARTs

 Total of 610 consecutive infertile men with a clinical varicocele  238 (39%) infertile men with bilateral clinical varicoceles  157 (66%) chose bilateral varicocelectomy Surgical (SUR) group  81 (34%) men chose not to have surgery Non-surgical (NON-SUR) group.

MEAN (±SD) BASELINE CLINICAL PARAMETERS SURNON-SURP-value Male age 35.8   5.1 NS Female age 34.0   4.7 NS Duration of infertility (months) 29.5   37.6 NS Percentage with secondary infertility 20%27%NS Left testicular volume (ml) 13.8   3.1 < Right testicular volume (ml) 14.7   3.1 <0.0001

MEAN (±SD) BASELINE CLINICAL PARAMETERS SURNON-SURP-value Serum FSH (IU/ml) 6.4   4.2 NS Serum LH (IU/ml) 4.6   2.6 NS Semen volume (ml) 3.1   2.5 NS Sperm concentration (x 10 6 /ml) 20.8   29.4 NS Sperm motility (% motile) 26.1   Sperm morphology (% normal forms) 40.4  

MEAN (± SD) SUR GROUP SEMEN PARAMETERS Pre-OPPost-OPP-value Semen volume (ml) 3.1   1.5 NS Sperm concentration (x10 6 /ml) 20.8 ± ± Motile sperm (%) 26.1   19.9 < TMC (x10 6 ) 17.0   49.6 < Sperm morphology (% normal) 40.4   22.1 NS

 Pregnancy outcome and ART utilization data available for: 67.5% (106/157) of SUR group 64% (52/81) of NON-SUR group.

MEAN (±SD) BASELINE CLINICAL PARAMETERS IN COUPLES WITH PREGNANCY OUTCOME DATA SURNON-SURP-value Semen volume (ml) 3.1   2.9 NS Sperm concentration (x 10 6 /ml) 20.1   30.1 NS Sperm motility (% motile) 25.0   TMC (x 10 6 ) 16.1   Sperm morphology (% normal) 37.7 ± ± 12.4NS Follow-up (months) 39.0 ± ± 14NS

PREGNANCY & ART UTILIZATION RATES IN COUPLES WITH PREGNANCY OUTCOME DATA SURNON-SURP-value Natural pregnancy rate 47%23% Natural + ART pregnancy rate 60%50%NS IUI Utilization22%35%NS ICSI Utilization23%46% Overall ART utilization (IUI + ICSI) 32%62%0.0012

 Bilateral varicocele repair, when compared to non-surgical management, was associated with: Significant improvements in semen parameters Significant increase in natural pregnancy rate Significantly less overall ART utilization

 For bilateral clinical varicoceles, microsurgical repair is a favourable option for treating couples with male factor infertility.