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Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

Shah R 1 , Agarwal A 2 , Kavoussi P 3 , Rambhatla A 4 , Saleh R 5 , Cannarella R 6 Show all authors , Harraz AM 7 , Boitrelle F 8 , Kuroda S 9 , Hamoda TAA 10 , Zini A 11 , Ko E 12 , Calik G 13 , Toprak T 14 , Kandil H 15 , Gül M 16 , Bakırcıoğlu ME 17 , Parekh N 18 , Russo GI 19 , Tadros N 20 , Kadioglu A 21 , Arafa M 9 , Chung E 22 , Rajmil O 23 , Dimitriadis F 24 , Malhotra V 25 , Salvio G 26 , Henkel R 27 , Le TV 28 , Sogutdelen E 29 , Vij S 18 , Alarbid A 30 , Gudeloglu A 31 , Tsujimura A 32 , Calogero AE 6 , El Meliegy A 33 , Crafa A 6 , Kalkanli A 34 , Baser A 35 , Hazir B 36 , Giulioni C 37 , Cho CL 38 , Ho CCK 39 , Salzano C 40 , Zylbersztejn DS 41 , Tien DMB 28 , Pescatori E 42 , Borges E 43 , Serefoglu EC 44 , Saïs-Hamza E 8 , Huyghe E 45 , Ceyhan E 46 , Caroppo E 47 , Castiglioni F 48 , Bahar F 49 , Gokalp F 50 , Lombardo F 51 , Gadda F 52 , Duarsa GWK 53 , Pinggera GM 54 , Busetto GM 55 , Balercia G 26 , Cito G 56 , Blecher G 57 , Franco G 58 , Liguori G 59 , Elbardisi H 60 , Keskin H 31 , Lin H 61 , Taniguchi H 62 , Park HJ 63 , Ziouziou I 64 , de la Rosette J 65 , Hotaling J 66 , Ramsay J 67 , Molina JMC 68 , Lo KL 69 , Bocu K 70 , Khalafalla K 60 , Bowa K 71 , Okada K 72 , Nagao K 73 , Chiba K 72 , Hakim L 74 , Makarounis K 75 , Hehemann M 76 , Rodriguez Peña M 77 , Falcone M 78 , Bendayan M 8 , Martinez M 79 , Timpano M 78 , Altan M 80 , Fode M 81 , Al-Marhoon MS 82 , Sadighi Gilani MA 83 , Soebadi MA 84 , Gherabi N 85 , Sofikitis N 86 , Kahraman O 46 , Birowo P 87 , Kothari P 88 , Sindhwani P 89 , Javed Q 90 , Ambar RF 91 , Kosgi R 92 , Ghayda RA 93 , Adriansjah R 94 , Condorelli RA 6 , La Vignera S 6 , Micic S 95 , Kim SHK 96 , Fukuhara S 97 , Ahn ST 98 , Mostafa T 33 , Ong TA 99 , Takeshima T 100 , Amano T 101 , Barrett T 102 , Arslan U 14 , Karthikeyan VS 103 , Atmoko W 92 , Yumura Y 100 , Yuan Y 104 , Kato Y 105 , Jezek D 106 , Cheng BK 107 , Hatzichristodoulou G 108 , Dy J 109 , Castañé ER 110 , El-Sakka AI 111 , Nguyen Q 112 , Sarikaya S 113 , Boeri L 52 , Tan R 114 , Moussa MA 115 , El-Assmy A 7 , Alali H 116 , Alhathal N 117 , Osman Y 7 , Perovic D 118 , Sajadi H 88 , Akhavizadegan H 119 , Vučinić M 120 , Kattan S 117 , Kattan MS 117 , Mogharabian N 121 , Phuoc NHV 28 , Ngoo KS 122 , Alkandari MH 123 , Alsuhaibani S 124 , Sokolakis I 108 , Babaei M 125 , King MS 69 , Diemer T 126 , Gava MM 91 , Henrique R 127 , Silva RSE 91 , Paul GM 128 , Mierzwa TC 129 , Glina S 91 , Siddiqi K 130 , Wu H 131 , Wurzacher J 132 , Farkouh A 9 , Son H 133 , Minhas S 134 , Lee J 135 , Magsanoc N 136 , Capogrosso P 137 , Albano GJ 79 , Lewis SEM 138 , Jayasena CN 139 , Alvarez JG 140 , Teo C 141 , Smith RP 142 , Chua JBM 143 , Jensen CFS 144 , Parekattil S 145 , Finelli R 9 , Durairajanayagam D 146 , Karna KK 9 , Ahmed A 147 , Evenson D 148 , Umemoto Y 149 , Puigvert A 150 , Çeker G 151 , Colpi GM 152 , Global Andrology Forum

Affiliations 

  • 1 Division of Andrology, Department of Urology, Lilavati Hospital and Research Centre, Mumbai, India
  • 2 American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA. agarwaa@ccf.org
  • 3 Austin Fertility & Reproductive Medicine/Westlake IVF, TX, USA
  • 4 Department of Urology, Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
  • 5 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Sohag University, Sohag, Egypt
  • 6 Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
  • 7 Mansoura University Urology and Nephrology Center, Mansoura, Egypt
  • 8 Department of Reproductive Biology, Fertility Preservation, Andrology, CECOS, Poissy Hospital, Poissy, France
  • 9 American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
  • 10 Department of Urology, King Abdulaziz University, Jeddah, Saudi Arabia
  • 11 Division of Urology, Department of Surgery, McGill University, Montreal, QC, Canada
  • 12 Department of Urology, Loma Linda University Health, Loma Linda, CA, USA
  • 13 Department of Urology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
  • 14 Department of Urology, Fatih Sultan Mehmet Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
  • 15 Fakih IVF Fertility Center, Abu Dhabi, UAE
  • 16 Department of Urology, Selcuk University School of Medicine, Konya, Turkey
  • 17 SENSART Clinic, Istanbul, Turkey
  • 18 Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
  • 19 Urology Section, University of Catania, Catania, Italy
  • 20 Division of Urology, Southern Illinois University School of Medicine, Springfield, IL, USA
  • 21 Section of Andrology, Department of Urology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
  • 22 Department of Urology, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
  • 23 Department of Andrology, Fundacio Puigvert, Barcelona, Spain
  • 24 Department of Urology, Aristotle University of Thessaloniki, Thessaloniki, Greece
  • 25 SCM Clinic and Hospital, New Delhi, India
  • 26 Department of Endocrinology, Polytechnic University of Marche, Ancona, Italy
  • 27 Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
  • 28 Department of Andrology, Binh Dan Hospital, Ho Chi Minh City, Vietnam
  • 29 Department of Urology, Bolu Abant Izzet Baysal University, Bolu, Turkey
  • 30 Department of Surgery, Urology Unit, Farwaniya Hospital, Farwaniya, Kuwait
  • 31 Department of Urology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
  • 32 Department of Urology, Juntendo University Urayasu Hospital, Chiba, Japan
  • 33 Department of Andrology, Sexology and STIs, Faculty of Medicine, Cairo University, Cairo, Egypt
  • 34 Department of Urology, Taksim Education and Research Hospital, Istanbul, Turkey
  • 35 Department of Urology, Faculty of Medicine, Bandırma Onyedi Eylül University, Balıkesir, Turkey
  • 36 Reproductive medicine, Clinical Research Centre, Lund University, Malmö, Sweden
  • 37 Department of Urology, Polytechnic University of Marche Region, Ancona, Italy
  • 38 S. H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
  • 39 Department of Urology, Universiti Teknologi Mara (UiTM) Specialist Centre, Selangor, Malaysia
  • 40 PO San Giovanni Bosco, ASL Napoli 1 Centro, Napoli, Italy
  • 41 Fleury Group and Hospital Israelita Albert Einstein, São Paulo, Brazil
  • 42 Andrology and Reproductive Medicine Unit, Gynepro Medical, Bologna, Italy
  • 43 Fertility Medical Group, São Paulo, Brazil
  • 44 Department of Urology, Biruni University School of Medicine, Istanbul, Turkey
  • 45 Department of Urology and Andrology, University Hospital of Toulouse, France
  • 46 Department of Urology, School of Medicine, Baskent University, Konya, Turkey
  • 47 Asl Bari, PTA "F Jaia", Reproductive and IVF unit, Andrology Outpatients Clinic, Asl Bari, Conversano (Ba), Italy
  • 48 Andrology Unit, ART Center - San Carlo Clinic, Paderno Dugnano, Milan, Italy
  • 49 Andrology Section, Siloam Sriwijaya Hospital, Palembang, Indonesia
  • 50 Department of Urology, Hatay Mustafa Kemal University, Antakya, Turkey
  • 51 Laboratory of Seminology-Sperm Bank "Loredana Gandini", Department of Experimental Medicine, University of Rome "Sapienza", Rome, Italy
  • 52 Department of Urology, IRCCS Fondazione Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
  • 53 Department of Urology, School of Medicine, Udayana University, Denpasar, Indonesia
  • 54 Department of Urology, Innsbruck Medical University, Innsbruck, Austria
  • 55 Department of Urology and Organ Transplantation, University of Foggia, Ospedali Riuniti of Foggia, Foggia, Italy
  • 56 Department of Urology, University of Florence, Florence, Italy
  • 57 Department of Surgery, School of Clinical Sciences, Monash University, Melbourne, Australia
  • 58 Department of Urology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
  • 59 Department of Urology, University of Trieste, Trieste, Italy
  • 60 Department of Urology, Hamad Medical Corporation, Doha, Qatar
  • 61 Department of Urology, Peking University Third Hospital, Peking University, Beijing, China
  • 62 Department of Urology and Andrology, Kansai Medical University, Hirakata, Osaka, Japan
  • 63 Department of Urology, Pusan National University School of Medicine, Busan, Korea
  • 64 Department of Urology, College of medicine and pharmacy, Ibn Zohr University, Agadir, Morocco
  • 65 Department of urology, Faculty of Medicine, Istanbul Medipol Mega University Hospital, Istanbul, Turkey
  • 66 Department of Surgery (Urology), University of Utah, Salt Lake City, UT, USA
  • 67 Department of Andrology, Hammersmith Hospital, Imperial, London, UK
  • 68 Servicio de Urología, Hospital Clínico de Barcelona, Barcelona, Spain
  • 69 Division of Urology, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
  • 70 Department of Urology, Silopi State Hospital, Sirnak, Turkey
  • 71 Department of Urology, School of Medicine and Health Sciences, University of Lusaka, Lusaka, Zambia
  • 72 Department of Urology, Kobe University Graduate School of Medicine, Kobe, Japan
  • 73 Department of Urology, Toho University Faculty of Medicine, Tokyo, Japan
  • 74 Department of Urology, Universitas Airlangga/Rumah Sakit Universitas Airlangga Teaching Hospital, Surabaya, Indonesia
  • 75 Department of Urology and Andrology, Locus Medicus, Athens, Greece
  • 76 Department of Urology, University of Washington, Seattle, WA, USA
  • 77 Instituto de Ginecología y Fertilidad (IFER), Universidad de Buenos Aires, Buenos Aires, Argentina
  • 78 Department of Urology, Molinette Hospital, A.O.U. Città della Salute e della Scienza, University of Turin, Torino, Italy
  • 79 Section of Urology, Department of Surgery, University of Santo Tomas Hospital, Manila, Philippines
  • 80 Department of Urology, Haceppete University, Ankara, Turkey
  • 81 Department of Urology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
  • 82 Department of Surgery, Urology Division, Sultan Qaboos University, Muscat, Oman
  • 83 Department of Andrology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
  • 84 Department of Urology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
  • 85 Andrology Committee of the Algerian Association of Urology, Algiers, Algeria
  • 86 Department of Urology, Ioannina University School of Medicine, Ioannina, Greece
  • 87 Department of Urology, Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
  • 88 B.Y.L Nair Ch Hospital, Mumbai, India
  • 89 Department of Urology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
  • 90 Department of Urology, Al - Ahlia Hospital Abu Dhabi UAE, Abu Dhabi, UAE
  • 91 Department of Urology, Centro Universitario em Saude do ABC, Santo André, Brazil
  • 92 Department of Urology and Andrology, AIG Hospitals, Hyderabad, Telangana, India
  • 93 Urology Institute, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
  • 94 Department of Urology, Faculty of Medicine Universitas Padjadjaran, Hasan Sadikin General Hospital, Banding, Indonesia
  • 95 Department of Andrology, Uromedica Polyclinic, Belgrade, Serbia
  • 96 IVF Australia, Sydney, New South Wales, Australia
  • 97 Department of Urology, Graduate School of Medicine, Osaka University, Osaka, Japan
  • 98 Department of Urology, Korea University College of Medicine, Seoul, Korea
  • 99 Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
  • 100 Department of Urology, Reproduction Center, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
  • 101 Department of Urology, Nagano Red Cross Hospital, Nagano, Japan
  • 102 Perth Urology Clinic, Perth, WA, Australia
  • 103 Andrology Unit, Department of Urology, Apollo Hospitals, Greams Road, Chennai, India
  • 104 Andrology Center & Urology Department, Peking University First Hospital, Peking University, Beijing, China
  • 105 Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
  • 106 Department for Transfusion Medicine and Transplantation Biology, Reproductive Tissue Bank, University of Zagreb, School of Medicine, University Hospital Zagreb, Zagreb, Croatia
  • 107 Department of Surgery, United Christian Hospital, Hong Kong, China
  • 108 Department of Urology, Martha-Maria Hospital Nuremberg, Nuremberg, Germany
  • 109 Stone and Prostate Treatment Services/Pelvic Floor Center and Anorectal Diseases, St. Luke's Medical Center, Quezon City, Metro Manila, Philippines
  • 110 Department of Andrology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
  • 111 Department of Urology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
  • 112 Center for Andrology and Sexual Medicine, Viet Duc University Hospital, Hanoi, Vietnam
  • 113 Department of Urology, Gülhane Research and Training Hospital, University of Health Sciences, Ankara, Turkey
  • 114 Advanced Urology Associates, Singapore
  • 115 Department of Urology, Lebanese University, Beirut, Lebanon
  • 116 King Fahad Specialist Hospital, Dammam, Saudi Arabia
  • 117 King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
  • 118 Urology and Andrology Center, CODRA Hospital, University of Montenegro, Podgorica, Montenegro
  • 119 Department of Urology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
  • 120 Department of Urology, Užice General Hospital, Zlatibor, Serbia
  • 121 Sexual Health and Fertility Research Center, Shahroud University of Medical Sciences, Shahroud, Iran
  • 122 Urology Unit, Department of Surgery, Hospital Angkatan Tentera Tuanku Mizan, Kuala Lumpur, Malaysia
  • 123 Department of Urology, Mubarak Al-Kabeer Teaching Hospital, Kuwait University, Jabriya, Kuwait
  • 124 Department of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
  • 125 Department of Andrology, Shariati Medical Center, Tehran University of Medical Sciences, Tehran, Iran
  • 126 Department of Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen (GER), University Hospital Giessen and Marburg GmbH, Campus Giessen, Giessen, Germany
  • 127 Santa Casa de Ribeirão Preto, Ribeirão Preto, Brazil
  • 128 Department of Urology, Hospital de Clínicas of the Federal University of Paraná, Curitiba, Brazil
  • 129 Androlab, Fertility Clinic, Curitiba, Brazil
  • 130 Department of Urology, Cleveland Clinic, Abu Dhabi, UAE
  • 131 Department of Andrology, PKU 3rd Hospital Reproductive Medicine Center, Beijing, China
  • 132 Department of Urology, University Hospital Innsbruck, Innsbruck, Austria
  • 133 Department of Urology, SMG-SNU Boramae Medical Center, Seoul, Korea
  • 134 Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
  • 135 Department of Urology, National University Hospital, Singapore
  • 136 Department of Surgery, University of the Philippines College of Medicine, Manila, Philippines
  • 137 Department of Urology, University of Insubria, Varese, Italy
  • 138 Examenlab Ltd., Northern Ireland, UK
  • 139 Department of Reproductive Endocrinology and Andrology, Imperial College London, London, UK
  • 140 Department of Andrology, Centro ANDROGEN, La Coruña, Spain
  • 141 Department of Urology, Gleneagles Hospital, Singapore
  • 142 Department of Urology, University of Virginia School of Medicine, Virginia, USA
  • 143 Department of Urology, East Avenue Medical Center, Quezon City, Philippines
  • 144 Department of Urology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
  • 145 Avant Concierge Urology & University of Central Florida, Winter Garden, FL, USA
  • 146 Department of Physiology, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor, Malaysia
  • 147 Department of Urology, Sabah Al Ahmad Urology Center, Kuwait City, Kuwait
  • 148 SCSA Diagnostics, Brookings, SD, USA
  • 149 Department of Nephro-Urology, Nagoya City West Medical Center, Nagoya, Japan
  • 150 Urological and Human Reproduction Unit, Quiron Hospital, Barcelona, Spain
  • 151 Department of Urology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
  • 152 Next Fertility Procrea, Lugano, Switzerland
World J Mens Health, 2023 Jan;41(1):164-197.
PMID: 35791302 DOI: 10.5534/wjmh.220048

Abstract

PURPOSE: Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility.

MATERIALS AND METHODS: Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field.

RESULTS: The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available.

CONCLUSIONS: This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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