Microsurgical varicocelectomy: novel applications to optimize patient outcomes

Fertile Battle
Microsurgical varicocelectomy: novel applications to optimize patient outcomes

Volume 112, Issue 4, Pages 632–639


Larry I. Lipshultz, M.D., Ranjith Ramasamy, M.D., Jay I. Sandlow, M.D., James Hotaling, M.D., Michael Eisenberg, M.D., Craig Niederberger, M.D., Robert E. Brannigan, M.D.


PRO: Emerging data supports the application of microsurgical varicocelectomy for several new indications

CON: More evidence is needed before broadening the indications for microsurgical varicocelectomy

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I agree with the following:
Emerging data supports the application of microsurgical varicocelectomy for several new indications
More evidence is needed before broadening the indications for microsurgical varicocelectomy
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Go to the profile of Pandiyan  Natarajan
almost 3 years ago

Thank you very much for the wonderful Fertile Battle.

It is amazing that a surgical procedure (1) introduced in 1952 without a randomised controlled clinical trial in the pre ART/IUI era is still surviving nearly 70 years later. We must congratulate the Urologists/Surgeons  around the world for keeping this myth going. I am an Andrologist and Reproductive Endocrinology and Infertility Specialist since 1985. I was doing Varicocelectomy. I stopped since 2005.

There are several strange things about Varicocele. No one knows how it impairs semen parameters, how it causes low testosterone or increases DNA fragmentation. Theories abound.  It was raised scrotal temperature initially. Then it was refluxing adrenal cortical metabolites. With the advent of molecular biology, it is now increased DNA fragmentation. All theories remain unproven. 

In all paired organs one normal organ is good enough for all physiological functions. By a strange twist of logic even unilateral varicocele has been implicated in bilateral testicular impairment.

Even more strange is the fact there is no clear evidence as to in whom it will improve all these parameters. The country which introduced Varicocelectomy (UK) has now given it up. NICE ( National Institute of Clinical Excellence, UK) recommends - DO NOT DO Varicocelectomy.(2) It is strange that American Urology Association and American Society of Reproductive Medicine (ASRM) still endorse it in  ART era.

Most of us who have been long enough in this field, now know that, all these parameters, semen analysis, testosterone values and DNA  fragmentation vary from time to time in the same individual. (3)

We  do not yet have a clear definition of Oligo Astheno Teratozoospermia. This is being redefined with every new edition of the WHO manual. Many patients with Non obstructive azoospermia do show evidence of spermatozoa in the ejaculate on repeat semenalysis. Besides, repeat semenalysis often show  evidence of progression to the mean or regression to the mean.(3)

Testosterone levels vary widely in men with Erectile Dysfunction and in men with Normal sexual function. The relationship between Testosterone levels, (except when it is very low) and erectile dysfunction is nebulous at best. The Cochrane conclusion clearly indicates that this claimed association is of  very low quality evidence. 

The ASRM has clearly indicated in its guideline that DNA Fragmentation Tests are not ready for prime time.(4) To propose surgery for improving an hypothetical number is playing the numbers game and not based on evidence required for introducing a new indication for an existing unproven surgical technique. DNA fragmentation tests at best may be a useful research tool with no clear current clinical utility. (5) 

Varicocelectomy was, is and if continued will remain an empirical surgical procedure. Adding hormone assays, DNA Fragmentation Tests and  testicular histology makes it Enlightened Empiricism.(6)

The most expensive commodity for Infertile couple and to all of us is TIME. Infertility is a race against TIME. It would be a waste of time to do a surgical procedure and wait for 3, 6 or 12 months, hoping for an improvement in semen parameters, testosterone levels and DNA fragmentation index when there are much simpler measures of treating all of them as has been clearly indicated by the Con proponents. 


1) Tulloch, W.S. Consideration of sterility; subfertility in the male. Edinburg Med J. 1952; 59: 29–34

2) https://www.nice.org.uk/donotdo/men-should-not-be-offered-surgery-for-varicoceles-as-a-form-of-fertility-treatment-because-it-does-not-improve-pregnancy-rates

3) Pandiyan N. Semen Analysis—A Numbers Game Chettinad Health City Medical Journal 2012;1:2-http://www.chcmj.ac.in/journal/pdf/vol1_no1/01_Semen%20Analysis%20-%20A%20Numbers%20Game.pdf

4) Practice Committee of the American Society for Reproductive Medicine. The clinical utility of sperm DNA integrity testing: a guideline. Fertil Steril 2013;99:673-7


5) Pandiyan N, Pandiyan R, Raja DR. A perspective on sperm DNA fragmentation. Transl Androl Urol 2017;6:S661-4. 10.21037/tau.2017.03.84


6) Pandiyan N. Whither varicocelectomy? Chettinad Health City Medical Journal 2014;3:2-


Professor Dr Pandiyan Natarajan,

Chief Consultant in Andrology and Reproductive Medicine and Head of the Department,

Chettinad Super Speciality Hospital,


Tamil Nadu, India-603103