Evers Johannes Hans L H, Collins John, Clarke Jane
Department of Obstetrics & Gynaecology, Academisch Ziekenhuis Maastricht, PO Box 5800, Maastricht, Netherlands, 6202 AZ.
Cochrane Database Syst Rev. 2009 Jan 21(1):CD000479. doi: 10.1002/14651858.CD000479.pub4.
A varicoceles is a meshwork of distended blood vessels in the scrotum, usually left-sided, due to dilatation of the spermatic vein. Although the concept that varicoceles causes, and varicocelectomy cures, male subfertility has been around for almost fifty years, the mechanisms by which varicoceles would affect fertility have not yet been satisfactorily explained, and neither have the mechanisms by which varicocelectomy would restore fertility. Furthermore, it has been questioned whether a causal relation exists at all between the distension of the pampiniform plexus and impairment of fertility.
To evaluate the effect of varicoceles treatment on pregnancy rate in subfertile couples.
We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (12 Sept 2003 and October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004 and Issue 4, 2007), MEDLINE (January 1966 to October 2007), EMBASE (January 1985 to October 2007) and reference lists of articles. In addition, we handsearched specialist journals in the field from their first issue until 2007. We also checked cross-references, references from review articles and contacted researchers in the field.
Randomised controlled trials (RCTs) were included if they were relevant to the clinical question posed, if they reported pregnancy rates as an outcome measure, and if they reported data in treated (surgical ligation or radiological embolisation of the internal spermatic vein) and untreated groups.
Nine studies met the inclusion criteria for the original review. One was an extension of a previously published study, which left eight studies for analysis. All eight only included men from couples with subfertility problems; one excluded men with sperm counts less than 5 million per mL and one men with sperm counts less than 2 million per mL, with or without progressive motility of less than 10%. Two trials involving clinical varicoceles included some men with normal semen analysis. Three studies specifically addressed only men with subclinical varicoceles. Two authors independently screened potentially relevant trials. Any differences of opinion were resolved by consensus (none occurred for this review). Studies were excluded from meta-analysis if they made comparisons other than those specified above.
The combined Peto odds ratio (OR) of the eight studies is 1.10 (95%CI 0.73 to 1.68), indicating no benefit of varicoceles treatment over expectant management in subfertile couples in whom varicoceles in the man is the only abnormal finding.
AUTHORS' CONCLUSIONS: There is no evidence that treatment of varicoceles in men from couples with otherwise unexplained subfertility improves the couple's chance of conception.
精索静脉曲张是阴囊内扩张的血管网，通常发生在左侧，是由精索静脉扩张所致。尽管精索静脉曲张导致男性生育力低下以及精索静脉结扎术可治愈该病这一概念已存在近五十年，但精索静脉曲张影响生育力的机制尚未得到令人满意的解释，精索静脉结扎术恢复生育力的机制也未明确。此外，有人质疑蔓状静脉丛扩张与生育力受损之间是否存在因果关系。
评估精索静脉曲张治疗对不育夫妇妊娠率的影响。
我们检索了Cochrane月经紊乱与不育症研究组试验注册库（2003年9月12日和2007年10月）、Cochrane对照试验中央注册库（2004年第1期和2007年第4期《Cochrane图书馆》）、MEDLINE（1966年1月至2007年10月）、EMBASE（1985年1月至2007年10月）以及文章的参考文献列表。此外，我们还手工检索了该领域从创刊至2007年的专业期刊。我们还检查了交叉参考文献、综述文章中的参考文献，并联系了该领域的研究人员。
纳入的随机对照试验（RCT）需与提出的临床问题相关，将妊娠率作为结局指标进行报告，且报告治疗组（精索内静脉手术结扎或放射栓塞）和未治疗组的数据。
九项研究符合原始综述的纳入标准。其中一项是先前发表研究的扩展，因此剩下八项研究进行分析。所有八项研究仅纳入了不育夫妇中的男性；一项排除了精子计数低于每毫升500万的男性，另一项排除了精子计数低于每毫升200万的男性，无论其是否伴有进行性活动率低于10%。两项涉及临床精索静脉曲张的试验纳入了一些精液分析正常的男性。三项研究专门针对仅患有亚临床精索静脉曲张的男性。两位作者独立筛选潜在相关试验。如有任何意见分歧，通过协商解决（本综述未出现分歧）。若研究进行的比较超出上述规定范围，则排除在荟萃分析之外。
八项研究的合并Peto比值比（OR）为1.10（95%CI 0.73至1.68），表明在男性精索静脉曲张是唯一异常发现的不育夫妇中，精索静脉曲张治疗相较于期待治疗并无益处。
对于其他方面原因不明的不育夫妇中的男性，没有证据表明治疗精索静脉曲张能提高夫妇的受孕几率。
