How Varicocele(ctomy) Impacts on Couple Natural and Assisted Reproduction

Background: Varicocele may affect up to 35% of men with primary infertility and up to 80% of men with secondary in-fertility. The better semen parameters are, the more likely is spontaneous pregnancy; so, if varicocele repair improves se-men quality (in terms of sperm total count, motility, morphol-ogy and DNA integrity), it can consequently increase the preg-nancy probability. The aim of this study is to discuss the effect of varicocelectomy on spontaneous pregnancy but also on ART outcomes (IUI, IVF/ICSI).Material and Methods: English Literature was searched on PubMed for the terms of: varicocele repair, male infertility, OAT, DFI (=sperm DNA fragmentation index), IUI, IVF/ICSI. We evaluated publications of past five years about these topics (meta-analyses, reviews, prospective / controlled studies) and compared Literature results with our clinical practice and ex-perienced evidence. We have to underline the relevance of a careful selection of the patients to be addressed to varicocele repair, mainly based on an accurate diagnosis with colour-dop-pler ultrasound aimed to detect/confirm a basal spontaneous continuous reflux in orthostatism along the left spermatic vein - associated with at least one altered semen parameter, which we recently showed to be the most significant predictive factor of semen improvement.Results: A growing knowledge exists on the pathogenic mecha-nisms of varicocele and their consequences on spermatogenesis (hypoxia, hyperthermia, adrenal catabolites reflux to testis, ROS and DFI increase, and abnormal oxido-reduction potential of semen…). The most recent studies in the Literature confirm the positive role of varicocelectomy on spontaneous pregnancy rate in in-fertile couples without a major female factor.Insufficient evidence exists to determine if correcting varico-cele improves IUI outcomes, although some positive reports are available. Moreover, varicocele repair can often allow couples to use the less invasive form of ART.Prospective controlled studies concerning IVF/ICSI outcome - in terms of fertilization rate, pregnancy rate, live-birth rate and miscarriage rate – generally report better results after vari-cocelectomy in all the aforementioned rates: some conflicting results seem mainly due to bias regarding couples that achieve spontaneous pregnancy or with IUI after varicocelectomy, without undergoing IVF/ICSI as previously established. One of the most important effects of varicocele repair seems to be the seminal ROS and, consequently, sperm DFI decrease, a well known factor negatively affecting fertilization process and em-bryo development.Conclusions: Repair of clinical varicocele should be offered as a treatment option to affected infertile males, in order to im-prove semen parameters, to achieve more likely spontaneous pregnancies, to reduce the level of ART and also to obtain better IVF/ICSI outcome.