The varicocele dilemma

There is probably no subject that is more controversial in the area of male infertility than varicocele. The overwhelming majority of non-urologist in fertility specialists in the world are extremely sceptical of the role of v aricocele or varicocelectomy in the treatment of male infertility, Director s of most assisted reproductive technologies (ART) programmes view the enth usiasm with which urologists approach varicocelectomy as a potential impedi ment to the couple that is getting older and do not have much time left to become pregnant using ART. There are many credible, well-controlled studies which show no effect of varicocelectomy on fertility. There are also a few 'controlled' studies that favour varicocelectomy, but all can be criticise d on the basis of patient selection bias. Thus the great weight of evidence from controlled studies is against varicocelectomy and the reports support ing varicocelectomy are extremely weak. Finally, the reports that semen par ameters are improved by varicocelectomy is flawed by uncontrolled observati ons and the failure to take into account the variability of semen analysis in infertile men and its regression toward the mean. Many control studies h ave demonstrated that, because of this variability, men with an initially l ow sperm count tend later to have higher sperm counts in the absence of any treatment whatsoever.