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Article Title: Improved fertility after

varicocele correction: fact or fict

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Volume: 42 Issue: 2
MonthNear: 1984Pages: 249-56

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Article Author: Vermeulen A;Vandeweghe

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LITY AND STERILITY

nghl 1984 The American Fertility Society

Vol. 42, No. 2, August 1984

Prinred in U.SA.

proved fertility after varicocele correction: fact or fiction?*

Alex Vermeulen, M.D., Ph.D.t

Marc Vandeweghe, M.D.

Department of Endocrinology and Andrology, Medical Clinic, Academic Hospital,

State University of Ghent, Ghent, Belgium

Fertility after varicocele correction by embolization of the vena spermatica in 62

subjects was compared with fertility in an untreated group (n = 20) of subjects with
varicocele.
One year after varicocele correction of infertile males with oligozoospermia,
asthenozoospermia, or teratozoospermia but normal follicle-stimulating hormone
levels, 15 of 62 had achieved a pregnancy; in the untreated group, 8 had achieved a
pregnancy. Comparison of results by cumulative pregnancy rate analysis reveals that
the pregnancy rate was only marginally higher in the treated group. Varicocele
correction induced only a modest improvement of sperm quality; the severity of
varicocele had no influence either on sperm characteristics or on the outcome of
treatment. It is concluded that the effects of varicocele correction on the pregnancy rate
can be seriously doubted and that large-scale prospective studies are urgently required
to determine whether or not varicocele correction improves the pregnancy rate and
which subjects could eventually benefit from the treatment. Fertil Steril 42:249, 1984

Clinically evident varicocele, or varicosity of

e testicular veins, is found in - 10% to 23% of
erwise normal males. 1 In in(sub)fertile males,
inically evident varicocele is reported to have
incidence of - 30%, 1 2 suggesting that varicole might play a role in infertility, although the
gher incidence in males consulting for infertilmight be the consequence of a bias due to a
ore ready referral by the general practitioner of
infertile male to an andrologist when a varicole is observed. This may also explain why some
uthors 3 report a much lower incidence of varico-

*Supported in part by grant 3.0009.82 of the Fonds voor

Wetenschappelijk Geneeskundig Onderzoek (F.W.G.0.),
ssels, Belgium.
tReprint requests: A. Vermeulen, M.D. , Ph.D., Department
Endocrinology and Andrology, State University of Ghent,
ical Clinic/Academic Hospital, B 9000 Ghent, Belgium.
ol. 42, No. 2, August 1984

cele in the infertile population, whereas others 4

question the role of varicocele in infertility. Correction of varicocele is generally advocated as a
means of treating the subfertility in these subjects. Pregnancies after correction of the varicocele have been reported in up to 53% of cases, 5 but
other investigators 1 6 obtained less impressive
results and even doubt the efficacy of varicocele
correction as far as fertility is concerned. 7 - 10 The
causes of these divergent results may be differences in the selection of patients treated (duration of infertility; primary or secondary infertility), or a posteriori exclusion, on the basis of a
minor gynecologic abnormality in the partner, of
"unsuccessfully," but not of successfully, treated
patients. Moreover, in many studies it is not clear
what percentage of treated patients was available
for the follow-up study, or for what reason they
dropped out; whereas in others many patients received additional treatment. Finally, many studies are uncontrolled, lacking an untreated control

Vermeulen and Vandeweghe Fertility after varicocele correction

249

group having gone through the same investigative procedures as the treated group.
We thought it of interest therefore to report
here the results obtained in a well-defined group
of patients with varicocele who consulted for infertility. Results observed after correction of the
varicocele were compared with results observed
in a comparable, albeit smaller, group of subjects
with varicocele, who after consultation and exploration impregnated their partners before their
varicoceles could be corrected or who, obliteration
of the varicocele by Bucrylate (Ethicon, Hamburg, FRG) appearing to be impossible (see below), refused further treatment. Moreover, we
wondered whether the sperm characteristics of
subjects who achieved pregnancy either before or
after treatment permitted prediction of the outcome of treatment, and whether varicocele correction improved sperm characteristics.
MATERIALS AND METHODS

Subjects selected for this study consulted for

infertility, defined as failure to achieve a pregnancy after at least 1 year of unprotected coitus at
a normal frequency and with adequate technique.
Only subjects with oligozoospermia ( < 20 x
106 /ml), asthenozoospermia ( < 40%, 3 and 2 +
motility), or teratozoospermia ( < 30% spermatozoa with ideal morphology) in any combination,
on repeated examinations, were retained for this
study.11 12 Moreover, all patients with increased
follicle-stimulating hormone levels(> 5 ng/ml) on
two consecutive occasions were excluded, because
it was considered that chances of success in terms
of pregnancy were minimal in the latter.
In order for the patient to be included in the
study, the female partner had to be free of gynecologic abnormalities and to have apparently ovulatory cycles, as suggested by basal body temperature and/or luteal phase plasma progesterone levels. Some of the women, however, had some irregularity in the cycle.
All married patients with varicocele, consulting for infertility, satisfying the above-mentioned
criteria, and treated in our clinic between June 1,
1979, and November 15, 1982, have been included
in this study, insofar as follow-up of at least 1
year after treatment (or completion of exploration) was obtained. Only patients whO had their
diagnostic workup in our department and.Jiad
their varicocele corrected on our indications were
included in the study. Unmarried couples were
250

excluded, because it proved difficult to ascertain

the stability of their relationship and hence to
evaluate "infertility." Patients treated elsewhere
were excluded because this would have introduced a bias, only failures of treatment seeking
additional advice.
Of 88 subjects who satisfied the criteria, 6 refused to collaborate in the study. The mean age of
the 82 participants was 28 .8 3.3 years (range,
23 to 42 years); infertility was secondary in 8
patients (2 of these did not have their varicocele
corrected; see further).
Varicoceles were graded as subclinical if the
clinical examination was negative but bilateral
phlebography of the spermatic vein was positive
grade I if the varicocele could only be palpated
after the Valsalva maneuver in the upright position; grade II ifthe varicocele was palpable in the
upright position; and grade III if the varicocele
was visible without the Valsalva maneuver.
Varicocele was always ascertained by bilateral
retrograde selective venography of the venae
spermaticae. Indication for the venographic ex
ploration was clinically evident varicocele, posi
tive thermography, or positive Doppler flow. Posi
tive venography was considered as the ultimate
proof of varicocele. In 82% of cases the varicocele
was left-sided, in 16% it was bilateral, and in 2%
it was right-sided. In most cases, immediately
after venography, the spermatic vein was obliter
ated by injection of Bucrylate; the completenesso(
the obstruction ofreflux was immediately verified
by injection of contrast fluid; in 14 cases, oblitera
tion was impossible or unsuccessful because
complexity of the venous structures responsibl
for reflux; in these subjects reflux was corrected,
generally within the next few weeks, by surgery
In toto, 62 subjects (mean age, 28.6 3.2 years;
range 23 to 42 years) had their varicoceles cor
rected.
After diagnosis of varicocele, some patients
fused correction of reflux (especially when transcatheter occlusion was impossible or unsucce
ful) or conceived before the planned varicoce
correction could be performed. This group (n 20; mean age, 29.2 3.6 years [standard devi
tion]; range, 24 to 37 years), which satisfied
same criteria as the "treated" group, altho
relatively small, served as a control group forth
study.
Among the subjects who impregnated the'
wives before phlebography was performed, on!
those with clinically evident varicoceles were

Vermeulen and Vandeweghe Fertility after uaricocele correction

Fertility and Ste

I. Age and Duration ofInfertility in Different Groups of

. ts
Duration of
infertilityb

Ageb

Subjects

yr

mo

28.6 3.2 (23-42)

30 (12-84)

28.5 2.7 (24-35)

28.8 3.5 (23-42)
29.5 3.5 (24-37)

26 (12-60)
32 (12-84)
37 (12-47)

29.4 3.8 (27-37)

29.5 3.5 (24-36)

30 (1 2-72)
42 (24-60)

"P, pregnancy achieved within 1 year; NP, no pregnancy

'eved within 1 year.
"Mean standard deviation; range in parentheses.

'ned; all other control subjects underwent phleaphy.

The results, in terms of success or failure to
tain a pregnancy, were evaluated in all subjects
year after correction. The approximate date of
nception was calculated from the (expected)
te of delivery as given by the patient.
Moreover, semen, collected by masturbation,
was analyzed at 3-month intervals for 1 year after
atment or until pregnancy was reported. In
tients who refused treatment, no systemic folow-up sperm analysis is available.
Data were analyzed statistically with the Krusbl-Wallis test (analysis of variance), the MannWhitney U-test, or the Wilcoxon signed rank test
for matched pairs.

RESULTS
Within 12 months of correction ofvaricocele, 15
24%; mean age, 28.3 2.7 years; range, 24 to 35

years) of 62 patients (6 with secondary infertility)

succeeded in impregnating their wives; in 4 of
these, infertility was secondary. Of those who did
not have their varicoceles corrected (n = 20), 8
impregnated their wives within 12 months of exploration; in all of these infertility was primary.
Thirteen (87%) of 15 conceptions in the treated
group occurred within 6 months of correction, 2
within the first month of correction. Of the eight
subjects who achieved pregnancy without being
treated, two did so within 1 month and two within
3 months of exploration, waiting for embolization;
the four others achieved pregnancy within 6
months of refusal of treatment.
Both in the treated and untreated groups, two
additional subjects impregnated their wives between the 13th and 18th month after treatment.
As can be seen in Table 1, the mean age and the
duration of infertility were similar in the treated
and untreated groups, whether or not the subjects
achieved pregnancy.
Comparison of mean sperm concentration, percentage of progressive motile sperm, motile
sperm density, and morphology in the untreated
group, with values in the groups that had their
varicoceles corrected later, reveals (Table 2) that
in the untreated group the sperm characteristics
were slightly better than in the treated group,
although none of the differences was statistically
significant (Kruskal-Wallis test). In the treated
group, precorrection morphology was better (P <
0.02) in those subjects who later achieved pregnancy, but other parameters were similar; in the
untreated group, all sperm characteristics were
similar, whether or not pregnancy was achieved.
In order to make treated and untreated groups
completely comparable, we eliminated from the

hie 2. Comparison of Sperm Characteristics (Mean Standard Deviation [SD] and Range) in the Treated and Untreated Groups
(Basal Values)
Treated group
Concentra- Progressive
ti on
motility
Complete group
Mean ::t SD
Range
Pregnancy achieved
Mean SD
Range
No pregnancy achieved
Mean SD
Range

Motile
sperm

Untreated group
Ideal
Concentra- Progressive
morphology
ti on
motility

Motile
sperm

Ideal
morphology

x Ja6!ml

x Ja61ml

x 106/ml

x Ja6!ml

24.5 24.6
(0.3-107)

29 12
(7-60)

8.9 12.4
(0.1-50)

12 11
(10-50)

28.2 26.3
(1.4-94)

38 18
(11-62)

14.0 15.5
(0.2-53.6)

17 14
(0-45)

27.7 25.4
(2.0-56.0)

32 18
(13-56)

10.4 12.2
(0.7-30)

17 12a
(0-40)

31.8 28.8
(1.4-94)

39 18
(15-62)

15.2 16.5
(0.4-53 .6)

16 14
(2-45)

23.3 24.5
(0.3-107)

28 16
(7-60)

8.5 12.5
(0.1-50)

10 11
(0-50)

26.9 25.0
(2.0-87)

38 20
(11-57)

13.0 15.0
(0.2-51.3)

18 14
(0-37)

p < 0.02; versus the group who after treatment did not achieve pregnancy (Mann-Whitney U-test).

Vol. 42, No. 2, August 1984

Vermeulen and Vandeweghe Fertility after varicocele correction

251

Table 3. Sperm Characteristics of the Treated and Untreated Groups (All Subjects > 1 million/ml Motile Sperm)
Treated group: > 1 million/ml motile sperm
Subjects"

All
Mean SD
p
Mean SD
NP
Mean SD

Concentra- Progressive
ti on
motility

Motile
sperm

Untreated group

Ideal
Concentra- Progressive
morphology
motility
tion

Motile
sperm

Ideal

morphology

x 106/ml

x uhml

x Ilflml

x 106/ml

30.1 24.3

37 14

11.7 12.0

16 12

28.3 27.0

38 18

14.6 15.4

16 15

28.1 21.1

44 10

12.5 10.8

17 12

29.4 29.6

38 18

15.9 17.4

14 16

30.8 25.6

35 15

10.7 12.7

14 12

26.9 25.0

38 19

13.0 15.0

18 14

ap, patients achieving pregnancy within 12 months; NP, no pregnancy.

treated group all subjects with < 1 x 106 motile

spermatozoa/ml ejaculate (n = 11). It can be seen
(Table 3) that the sperm characteristics of both
groups are now almost identical; however, the
outcome of varicocele correction, in terms of
pregnancy, remained unchanged (12 pregnancies
in 46, or 26%).
Table 4 shows that the severity of varicocele
was not related to the severity of impairment of
sperm characteristics, although in those with
subclinical varicocele sperm characteristics were
somewhat (although not statistically significantly) better than in the other groups; whereas Table
5 shows that the severity of varicocele is not a
determinant in the success rate: of the 12 patients
with grade III varicocele, 3 impregnated their
wives, versus 7 of 21 with subclinical varicocele.
Eliminating subclinical varicocele from this
study does not change the success rate substantially: in the treated group, 11 of 47 achieved
pregnancy; in the untreated group, 5 of 14.
After varicocele correction, sperm characteristics were not significantly improved (Table 6) except for a slight improvement in morphology;
analysis of the Wilcoxon paired signed rank test
revealed, however, that a statistically significant
improvement in morphology (P < 0.05) was only
observed in the "infertile" group.

DISCUSSION

Although after 1 year of unprotected coital ac

tivity only 85% of couples have achieved preg
nancy, 13 14 and although of the remaining 15%
an important fraction will achieve pregnancy in
the next year(s), all males who failed to impreg
nate their partners after at least 1 year of unprotected coitus qualified for this study, and resul
were evaluated 1 year after correction. Indeed, it
has been observed that after correction of vari
cele almost all ( 90%) pregnancies are achiev
within 1 year 2 15 ; moreover, after 1 year, t
pressure for alternative modes of treatment
comes very high, so that a large percentage
patients will drop out if alternatives are not p
posed. Therefore, we are skeptical when in
preting results of varicocele treatment evalua
up to several years after correction, because m
will have dropped out and almost certainly so
patients will have sought additional "treatmen
Moreover, because varicocele patients are subfi
tile rather than infertile, pregnancies will
in the following years in a nonnegligible perc
age of subjects, independent of any treatment.
Of the patients (n = 88) that satisfied the
criteria, 82 (93%) accepted to participate in
study; only 6 refused (the reason for the refusal

Table 4. Severity of Varicocele and Sperm Characteristics

Degree
Subclinical (n
Mean SD
I (n = 21)
Mean SD
II (n = 28)
Mean SD
III (n = 12)
Mean SD

252

Volume

Density

Progressive motility

Motile sperm

ml

x 106/ml

x 106/ml

3.7 1.1

31.0 29.0

40 19

14.5 16.9

19.4 15.2

31 16

8.0 11.9

= 21)
3.1 1.3

........

2.9 2.1

22.0 27.4

23 15

7.5 11.6

3.6 2.0

23.3 18.1

30 21

7.8 9.2

Vermeulen and Vandeweghe

Fertility after varicocele correction

<:!

Table 5. Severity of Varicocele as a Prognostic Factor

Degree of varlcocele

Subclinical
varicocele

Varicocele corrected (n = 62)

Pregnancies
No pregnancies

4
11

3
13

6
17

2
6

15 (24%)
47 (76%)

2
6

15

16

23

62

3
3

1
4

3
2

1
3

8
12

0
1

20

7
14

4
17

9
19

3
9

23 (28%)
59 (72%)

2 (22%)
7 (78%)

21

21

28

12

82

Total
Varicocele untreated (n = 20)
Pregnancies
No pregnancies
Total
Total treated + untreated
Pregnancies
No pregnancies
Total

II ,

unknown). It may be reasonably assumed that

the success rate in the nonparticipants (dissatisfied patients ?) was rather lower than in the responders; hence, it is probable that the "success
rate" within 1 year of treatment is slightly overestimated. Our data show a success rate in terms
of pregnancy within 1 year of treatment of 24%.
This figure is rather low, but within the range of
successes reported in recent years (Table 7), differences being influenced by selection of patients,
duration of follow-up, and differences in the dropout rate.
As for the predictive value of pretreatment
sperm characteristics, only the mean percentage
of spermatozoa with ideal morphology was significantly (P < 0.02) higher in the "successful"
group (Table 2). Nevertheless, all pretreatment

Bilateral

Total

Ill

sperm characteristics were slightly better in the

group that achieved pregnancy than in the group
that did not; in the individual case, however, none
of the parameters had a highly predictive value,
pregnancies having been obtained with as low a
pretreatment sperm density as 1 to 2 million, a
motile sperm density of 100,000/ml, and < 5%
sperm with ideal morphology.
Neither did the degree of varicocele permit any
prediction of outcome, which is in agreement with
data in the literature. 16 Secondary infertility, on
the other hand, had a better prognosis, four of six
treated patients impregnating their wives within
12 months, and five of six within 18 months. Two
subjects with varicocele and secondary infertility
were not treated and did not impregnate their
wives within 12 months after exploration.

Table 6. Effect of Varicocele Correction on S perm Characteristics (Matched Pairs)

Mean initial values
Density
x

No pregnancy
3 months"
Mean SD
6 months
Mean SD
1 year
Mean SD
Pregnancy
6 months
Mean SD

Ja6t ml

Progressive
motility
%

Motile
sperm
x

la61ml

After treatment
Ideal
morphology

Density

Progressive
motility

x Ja61ml

Motile
sperm
x

Ideal
morphology

Ja6tml

23.8 26.5

28 16

8.3 13.1

9 10

24.8 27.1

28 21

9.9 16.6

13 19

22.8 25.7

28 17

8.2 12.7

8 10

23.5 27.5

22 11

7.3 12.8

16 24b

23.5 27.5

22 11

7.3 12.8

6 6

22.3 17.7

21 13

5.8 6.1

9 12

26.2 26.7

32 19

10.1 12.7

18 12c

24.3 24.0

39 17c

10.8 10.8

19 13

"Months after treatment, paired observations.

bp < 0.05, Wilcoxon treated pair signed rank, versu s pretreatment value.
'P < 0.02, namely, groups where no pregn a ncy was achieved.
Vol. 42, No. 2, August 1984

Ve rme ulen and Vandew e ghe

Fertility after uaricocele correction

253

Table 7. Results of Varicocelectomya

Reference

Selection criteria
n

Duration of
infertility

Semen
characteristics

Follow-up

Pregnancy
rate

Comments

mo

Brown (1976) 18
Bandhauer and Meili
(1977) 6

295

> 6

73

24
Rodriguez-Rigau et al.
operated
(1978) 7

> 12

986

> 12

Nilsson et al.
(1979) 8

51

> 24

Gogol et al. (1980) 15

64

> 12

Newton et al. (1980)16

149

Mattei et al. (1981) 20

140

Dubin and Amelar

(1978) 5

Oligoasthenoteratospermia
Oligoasthenoteratospermia
?

To 10 yrs
To 5 yrs
> 10 mos

Oligoastheno- > 1 to 12 yrs

teratospermia
Oligoastheno- 36-74 mos
teratospermia
Excluding:
azoospermia

> 41%
7%
45.8%

53%
8%

FSHb t

Abdelmassih et al.
(1982) 2 4
Rodriguez-Netto
(1982) 23

Soffer et al. (1983) 25

220

52

129

Oligoasthenospermia
?

18 mos

43.8%

1 to 3 yrs

31.6%

Bad postcoital 12 mos

test or severe oligo24 mos
zoospermia
Excluding:
azoospermia
FSH t
?
12 mos

Oligoasthenospermia

?
Average
12 mos
6/12/24 mos

20%
38%

40%

18%

51162/62% I
6/25/50% II
6/19/31 % III
2/10/31% IV

84 not operated: pregnancy

rate 50.9% (women
treated, including artificial
insemination by husband)
70% improvement of semen;
if > 10 x 106 /ml: 70~
pregnancies
45 untreated controls: 38't
pregnancies
Sperm count unchanged
after varicocele
Slightly improved motility and morphology
Highly significant
improvement of all sperm
characteristics
38 untreated for various
reasons, including azoospermia or elevated FSH
(!): 21 'lc (8) pregnancies
158 untreated controls:
10% pregnant after 1 yr,
18% pregnant after 2 yrs
(8 .2%/yr)

70% to 80'K of patients with improved semen characteristics after

surgery
56% of cases normalization of
sperm
18 only medical treatment: 3
pregnant
5 no treatment: 2 pregnant
I: only impaired semen quality
II: I + prostatovesiculitis
III: I + severe testicular fail
ure
IV : I + female factor
Controls: 14'K pregnant in 6
mo but significantly lower
sperm count (15.2 x
106 /m!) than operated
group (37.6 x 106 mil

For results before 1976 see Verstoppen and Steeno. 1

bFSH, follicle-stimulating hormone.

As to the influence of treatment on sperm characteristics, it can be seen (Table 6) that neither in
the successfully treated nor in the unsuccessfully
treated subjects did the mean values for sperm
254

characteristics show any statistically significant

improvement after treatment, with the possible
exception of morphology, in the unsuccessful
group. In the group that achieved pregnancy after

Vermeulen and Vandeweghe Fertility after varicocele correction

Fertility and Steril

Cu mu la t ive pregnancy rate

50 '/,

40

30

,q,o,,. ,...

\.\Q,~ :
/
/

20

/
/

/
/
/

I
I

10

I
w

8
I

I
I

,/,
I

2 3

4 5

10

18

15

Months since correction

resp . exploration

Figure 1
Cumulative pregnancy rates in corrected and uncorrected
varicocele.

treatment, only the percentage of progressive motile sperm increased. Complete normalization of
sperm (i.e. , concentration > 20 x 106 /ml, progressive motility > 40%, and > 30% ideal morphology on repeated examination) was obtained
in none of the patients who succeeded in impregnating their wives and in only 10% of those who
did not achieve pregnancy.
These data, showing only minimal improvement of sperm quality, as defined by the usual
parameters, are in contradiction with most data
in the literature5 15 - 18 (for a review of the literature before 1976 see Verstoppen and Steeno 1 ),
although Nilsson et al. ,8 Delaere and Loeber 19
and Mattei et al. 20 observed no improvement in
sperm quality after correction.
Rodriguez-Rigau et al. 7 only saw improvement
in the sperm count when the initial count was >
10 million/ml, but they found no correlation beVol. 42, No. 2, August 1984

tween improvement of sperm characteristics and

fertility. In other series, 21 however, pregnancies
occurred only when improvement of sperm was
observed, but MacLeod 2 1 observed an improvement of sperm quality in only 13% of patients.
The reason for the discrepancies in the literature is not apparent, but, again, selection of patients as well as the criteria of improvement used
by different investigators are rather variable.
The observation that most conceptions (87%)
occurred within 6 months after correction is in
agreement with data in the literature. 5 1 5 - 17
Rather surprising was the observation that of the
20 varicocele patients who fulfilled the same criteria as the treated group but did not have their
varicocele corrected, pregnancy was obtained
within 12 months in 8; in 4 of these a desire for
children had existed for more than 36 months!
Two additional subjects impregnated their wives
within 18 months after the first consultation.
This points perhaps to the role of psychologic factors in male infertility and makes relative the
so-called success rate after varicocele correction.
It would be an incorrect interpretation of the
data, however, to conclude that 40% (8 of 20) of
untreated varicocele patients achieved pregnancy
within 12 months of consultation. Indeed, pregnancies occurring while waiting for correction
should be related to the total number of subjects
waiting for treatment, including those who eventually will be treated. Therefore, cumulative conception rates, corrected for dropouts, are represented in Figure 1 for both treated and untreated
subjects. 22 It can be seen that in this study cumulative pregnancy rates in both treated and untreated subjects are rather similar.
Whereas most investigators are convinced of
the therapeutic value of the varicocele correction,
many point to the lack of suitably controlled studies and doubt the therapeutic value, in terms of
fertility , of varicocele correction and/or observed
in nontreated varicocele patients a pregnancy rate (almost ) as high as in the treated
groups 7 - 9 16 2 3 (Table 7). Recently, moreover,
Collins et al. ,26 in a 2- to 7-year follow-up study,
reported in untreated infertile couples a cumulative pregnancy rate comparable to the pregnancy
rate in treated couples. It should be pointed out
that studies reporting exceptionally high success
rates after varicocele correction, especially where
the study spreads over many years, may be biased
by the progressively increasing percentage of subjects lost to follow-up , which in most studies will

Vermeulen and Vandeweghe Fertility afte r varicocele correction

255

concern many more of the failures than the successes; indeed, the latter are generally cumulated
year after year, whereas the yearly inquiry is
often sent only to subjects not yet known to have
impregnated their wives; the "lost to follow-up"
concerns therefore only the latter group and not
those known to have fathered a child. Simple calculation reveals that this procedure may cause
very important overestimation of success rates.
The doubt concerning efficacy of treatment as
suggested by this study is strengthened by the
fact that clinically evident varicocele occurs in
15% to 20% of young adults and hence that the
majority of affected males should have normal
fertility; that there is no correlation between the
severity (degree) of venous reflux and either
sperm impairment or outcome of treatment; and
finally, that fertility after correction was not accompanied by a clear-cut improvement of sperm.
Our control group is certainly too limited to permit a definitive conclusion but points to the necessity for a large-scale, prospective controlled
study, with at random allocation of subjects to the
treated or the untreated group.
Acknowledgment. We thank Professor Marc Kunnen, who
skillfully performed the phlebography and Bucrylate embolization.

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