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Is It Time to Rethink Our Evaluation of Pediatric Varicoceles?

Op-Med is a collection of original articles contributed by Doximity members.

Varicoceles are dilated spermatic cord veins and are the most common correctable cause of male factor infertility. Prevalent in 10–15% of the general population, varicoceles have been shown to affect both spermatogenesis and testosterone production (1, 2). More importantly, varicoceles are found in 30% of men with primary infertility and up to 80% of men with secondary infertility (3). Numerous studies have demonstrated that varicocelectomy, a surgery performed by urologists that removes varicoceles, improves semen parameters including sperm concentration, motility, and morphology (1, 4, 5). Although performing a semen analysis to assess baseline semen parameters is part of the standard of care when assessing adult men presenting with varicoceles, the approach when assessing boys and adolescents with varicoceles is different. As urologists who often treat varicoceles in adolescent and adult men alike, we felt we needed to ask: is it time to change our approach in assessing varicoceles in this younger population?

Asking boys and adolescents with varicoceles to undergo semen analyses is considered taboo. Many may argue that times have changed but based on a recent twitter poll by the Society for the Study of Male Reproduction, more than half of participating physicians still do not routinely obtain or discuss getting a semen analysis in boys/adolescents with varicoceles. Instead, physicians base their decisions to operate on these boys by the physical exam. When assessing boys/adolescents with varicoceles, physicians compare testicular volume sizes, assess for testicular pain, and can consider semen analyses if available (6). Current recommendations are to correct a varicocele when there is more than a 20% ipsilateral testicular size discrepancy (7). Testicular size discrepancy without an ultrasound is a subjective tool, and with no studies assessing how testicular size discrepancy translates to fertility, there was a need to explore the accuracy of this surgical parameter and to find a more accurate and objective measure to determine the need for varicocelectomy in this population. 

At this year’s American Society for Reproductive Medicine (ASRM) Virtual Conference, we presented a retrospective study on whether testicular size discrepancy is an accurate assessment of the fertility of boys/adolescents with varicoceles. The study looked at boys under the age of 18 who were diagnosed with a varicocele and underwent varicocelectomy. It appeared that testicular size discrepancy, a parameter that is typically used to evaluate pediatric varicoceles, was not associated with semen parameters and is therefore not a good indicator for varicocelectomy in boys/adolescents.

This research project paves the way for physicians to reconsider the role of semen analysis as a diagnostic marker for boys/adolescents with varicoceles. The series demonstrates that current guidelines are not accurately determining which boys with varicoceles truly need surgical intervention if the goal is to improve fertility in addition to symptom relief. It is our belief that similar to adults, pediatric varicocele guidelines should no longer utilize testicular size discrepancy as the only diagnostic tool, but instead recommend using semen parameters to indicate if varicocele repair is indicated. Semen analysis may have some inaccuracies and variability, but it is still the best test of male infertility. The burden for change now depends on the physician: if we are to standardize using semen parameters in boys with varicoceles, we need to normalize the discussion of sex and fertility with patients and their parents. Many physicians may consider these conversations uncomfortable, but if we want to provide our patients with the best care, the conversation is necessary.

References

1. Agarwal A, Deepinder F, Cocuzza M, Agarwal R, Short RA, Sabanegh E, et al. Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology. 2007;70(3):532-8.

2. Chiles KA, Schlegel PN. Cost-effectiveness of varicocele surgery in the era of assisted reproductive technology. Asian J Androl. 2016;18(2):259-61.

3. Choi WS, Kim SW. Current issues in varicocele management: a review. World J Mens Health. 2013;31(1):12-20.

4. Baazeem A, Belzile E, Ciampi A, Dohle G, Jarvi K, Salonia A, et al. Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair. Eur Urol. 2011;60(4):796-808.

5. Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM. Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial. Eur Urol. 2011;59(3):455-61.

6. Chung JM, Lee SD. Current Issues in Adolescent Varicocele: Pediatric Urological Perspectives. World J Mens Health. 2018;36(2):123-31.

7. Diamond DA, Gargollo PC, Caldamone AA. Current management principles for adolescent varicocele. Fertil Steril. 2011;96(6):1294-8.

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