Varicocele: Dampak Kesuburan pada Pria

William Tendi
Supervisor: dr. Ponco Birowo, SpU(K), PhD
 Varicocele?
• Varicocele adalah pembesaran abnormal
plekus dari scrotum pampiniform
• Populasi pria yang mengalami infertil sekitar
35-40% (EAU 2020)
• Varicocele unilateral sering terjadi pada sisi kiri

EAU Guidelines 2020

Leslie FW. StatPearls 2020
 Pathophysiology
• Failure in the anti-reflux mechanism of the vein
• Angulation of the left internal spermatic vein
• Left renal vein entrapment by superior
mesenteric vein and aorta  “nutcracker
syndrome”

• Scrotal pain may occur, but most patients are

asymptomatic

Leslie FW. StatPearls 2020

 Classification
• Subclinical
• Grade I  palpable when Valsalva
• Grade II  palpable without Valsalva
• Grade III  visible

EAU Guidelines 2020

 Impact on Male Infertility
Increased testicular
temperature

Increased oxidative Testicular

stress and apoptosis- VARICOCELE hypoperfusio
associated microRNA n

Toxin
accumulatio
n
Partin AW et al. Campbell 12th ed. 2021
 Male Infertility
Infertility  inability to Infertility Obstructive
conceive despite regular
unprotected sex for at Non-
least 1 year Obstructive

Production
Product quality
process
(the spermatozoa)
(spermatogenesis)
• Optimal environment • DNA fragmentation
• Optimal nutrition

Varicocele

EAU Guidelines 2020

 Varicocele Treatment and Failure Rate
Preserved
artery

No Yes

Retroperitoneal (15-25%) Laparoscopic (3-15%)

Conventional inguinal (5-15%) Radiographic (15-25%)

Microsurgery (0.5-1%)

Partin AW et al. Campbell 12th ed. 2021

 Assisted Reproductive Technology (ART)
• Intra-uterine insemination (IUI)  not
recommended in sperm count <10 millions/mL
• In vitro Fertilization (IVF)
• Intracytoplasmic sperm injection (ICSI)

EAU Guidelines 2020

 Should it be treated?
Varicocelectomy is proven to Additional benefit:
increase: • Increased testosterone
• Sperm retrieval success rate • Lowering DNA
• Pregnancy and live birth rate fragmentation index
• Seminal parameters

Sperm Retrieval Success Rate

Birowo P, et al. Heliyon 2020

 Pregnancy Rate

Birowo P, et al. Heliyon 2020

 Live Birth Rate

Birowo P, et al. Heliyon 2020

 DNA Fragmentation Index

Birowo P, et al. Basic and Clinical Andrology 2020

 Testosterone Levels

Li F, et al. IJU 2012

Pre-ART Varicocelectomy
• The first sperm retrieval has the highest
chance of success, thus increasing the sperm
retrieval chance rate is beneficial
• Lowering the DNA damage  higher chance of
a successful ART
• Increasing chance of spontaneous pregnancy
 avoid the need of ART and lowering the cost
of fertility program
Conclusion
• Varicocele repair increases men fertility, both
natural and assisted
• The most recommended method in
varicocelectomy is microsurgical
• Varicocele repair before any type of ART might
be more cost-effective than direct ART
THANK YOU