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    Natural conception possible after varicocele repair

    Pregnancy rates may reach 25% following treatment, even without seminal improvement

    San Antonio-Repair of clinically significant varicoceles may result in nearly a 25% chance of natural conception, even in men who do not demonstrate significant improvements in their postoperative seminal parameters, according to University of Iowa researchers.

    "What we found was that about 23% of these people were able to achieve a clinical pregnancy, which is a higher rate than what is typically quoted as 15% for untreated varicoceles. So the conclusions we drew from this were that people who had a varicocele, despite non-improvement, don't necessarily need to immediately proceed to an in vitro fertilization," said Peter Fretz, MD, a resident at the University of Iowa School of Medicine, Iowa City, working with Jay Sandlow, MD, and colleagues.

    He said that about 35% of patients fail to improve following varicocele repair, but until now no study has examined what happens to these couples in terms of pregnancy rates. The Iowa researchers conducted a study examining 285 patients who underwent varicocele repair between July 1995 and March 2002. Only clinically significant varicoceles were repaired, and follow-up of at least 12 months was required to be included in pregnancy data, unless pregnancy was achieved earlier.

    Give it a year

    "Even after 6 months following repair, if you don't see a clinical improvement on paper in terms of seminal parameters, you can still counsel your couples that there is a good chance they can still get pregnant on their own without having to proceed directly to in vitro fertilization," said Dr. Sandlow, currently associate professor of urology at the Medical College of Wisconsin, Milwaukee.

    "This type of study has not been done before, and I think what we are seeing is that a lot of couples have been going right on to IVF when they haven't seen any improvement. Yet most experts know that it may take up to a year after the surgery to see all the pregnancies you are going to see."

    He said the study highlights that waiting a year is important because it takes that amount of time to see if a pregnancy may occur, even without seminal improvement. Dr. Sandlow said, for the current study, significant seminal improvement was defined as at least a 50% increase in motile sperm/mL, sperm/mL, or percentage of motility.

    Among the 285 patients who underwent varicocele repair, complete follow-up was available for 133 patients. Researchers found that 89 of these patients (67%) had a significant improvement in at least one of their seminal parameters, and 44 (33%) did not. Among the 133 patients, 49 (37%) achieved natural conception, and 84 patients (63%) did not.

    Dr. Sandlow said that 59 of the patients went on to IVF among the 84 patients who could not conceive naturally, and 61% of the IVF patients achieved a pregnancy. Among the 44 patients who did not show significant improvement in at least one of the seminal parameters, 23% (10 patients) achieved natural conception. He noted that male or female ages were not significantly different between the groups with or without improvement.

    "We certainly would like to see more patient numbers. We want to be sure there wasn't selection bias," Dr. Sandlow told Urology Times. "But my guess is that we would probably see even better results with larger numbers."

    He said unless the age of the female partner is an issue, couples should now be counseled to continue attempts at natural conception for 12 months following repair, even with lack of seminal improvement.

    Control group needed

    Urologist Spencer Land, MD, clinical instructor of urology at Loyola University, Maywood, IL, said the study provides important new information that is good news for patients. He said it provides a compelling argument for repairing clinical varicoceles. He also noted that the study had one obvious limitation.

    "The problem with this study, of course, as is the case with all varicocele studies, is that there is no control," Dr. Land said. "From their data, a significant number of patients who underwent the procedure had improvement, but how significant is this improvement we don't know because there is no control group to show there is an improvement in natural pregnancy rates."UT