[Clinical and economic efficiency of varicocelectomy in the treatment of male infertility].

Abstract

Varicocele remains the most common potentially correctable cause of male infertility. Data from clinical guidelines, systematic reviews, meta-analyses, and original studies on the clinical and economic efficiency of varicocele treatment are summarized in this review. In men with clinical varicocele and impaired spermatogenesis, surgical repair improves semen parameters, including the number of progressively motile spermatozoa, and increases the likelihood of natural pregnancy. Before assisted reproductive technologies (ART), surgery is associated with higher clinical pregnancy and live birth rates and may be economically beneficial by improving ART efficacy. In men with severe oligozoospermia, microsurgery may allow some patients to proceed to intrauterine insemination or postpone IVF/ICSI. In non-obstructive azoospermia (NOA), surgery may result in the appearance of spermatozoa in the ejaculate and increase the likelihood of successful sperm retrieval by micro-TESE; however, no consistent economic advantage of a "surgery-first" strategy over immediate micro-TESE+ICSI has been demonstrated. Antioxidant therapy moderately improves semen parameters and reduces sperm DNA fragmentation, but its effect on clinical pregnancy and live birth remains insufficiently established. Among the available techniques for varicocele repair, microsurgical subinguinal varicocelectomy demonstrates the most favorable profile in terms of efficacy, safety, and recurrence rates. Laparoscopic and endovascular techniques remain valid alternatives, whereas robot-assisted and exoscopic technologies require further evidence regarding their clinical and economic efficiency. Overall, the evidence base remains heterogeneous; large prospective studies with clinical pregnancy and live birth as endpoints are required to clarify the effectiveness and cost-effectiveness of different approaches.