Clinical Question: Does repairing varicoceles restore fertility?

Setting: Various (meta-analysis)

Study Design: Systematic review

Synopsis: These authors conducted an exhaustive search of the literature—MEDLINE, registry of controlled trials, meeting programs, hand searches of surgical journals, etc.—looking for randomized controlled studies of varicocele repair in subfertile couples. The authors independently screened potential articles and had planned to resolve discrepancies by consensus, but report that none occurred. The authors do not state whether the data were extracted independently.

Seven studies ultimately were included. The interventions were primarily surgical ligation, but one study used radiologic embolization. Generally, the methods of the included trials were poor. Markers that traditionally bias the data in favor of the intervention group were common; these included poor description of randomization process, lack of intention-to-treat analysis, and lack of blinding. Nonetheless, the data are intriguing.

Among 281 treated couples, 61 women (21.7 percent) became pregnant, while 50 of 259 women (19.3 percent) in the control couples became pregnant. For this to be a meaningful difference, the studies would have needed more than 3,000 couples in each group. The combined studies had enough power to detect at least a 10 percent absolute difference in the proportion of pregnancies.

Bottom Line: Even using studies that appear biased in favor of the intervention groups, this systematic review suggests that repairing varicoceles in subfertile couples is ineffective for restoring fertility. (Level of Evidence: 1a-)