Maheshwari Abha, Muneer Asif, Lucky Marc, Mathur Raj, McEleny Kevin
NHS Grampian, Aberdeen Fertility Centre, Aberdeen, UK.
Division of Surgery and Interventional Science, NIHR Biomedical Research Centre University College London Hospital, University College London, London, UK.
Hum Fertil (Camb). 2020 Jul 7:1-8. doi: 10.1080/14647273.2020.1785117.
Varicoceles are reported to be present in a significant proportion of men presenting with subfertility and are more common amongst this group than in the general population. Opinion still remains divided amongst clinicians managing male factor infertility as to whether varicoceles alter the probability of spontaneous conception and/or pregnancy and live birth rates after fertility treatment. The debate as to whether varicoceles should be treated or not has intensified in recent years. This is due to the concerns regarding the impact of varicoceles on not only conventional semen parameters, but also the potential effects that they may have at the cellular level (an increase in circulating reactive oxygen species (ROS) resulting in sperm DNA fragmentation, even when conventional semen parameters are within the normal reference ranges). It has been suggested that treating the varicocele may result in improvements in the semen parameters, the fertilization and pregnancy rates for both spontaneous pregnancy as well as following in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment. ICSI can still be used for Assisted Reproduction Treatment (ART) in the presence of suboptimal semen parameters. However, it is an invasive and expensive technique with potential adverse effects on the offspring. As far as we are aware, there are no randomized controlled trials comparing the clinical/cost effectiveness of varicocele treatment versus the immediate use of ICSI on pregnancy rates. Previous modelling exercises are old and do not take into consideration current practices and trends such as rising female age and time to pregnancy. The conflicting advice that patients sometimes receive, challenges our commitment to evidence-based practice. The only way to resolve the controversy is to undertake an appropriately powered randomized trial, assessing clinical- and cost-effectiveness and the time to pregnancy following varicocele treatment and comparing this to a no treatment group.
据报道，在患有生育力低下的男性中，相当一部分人存在精索静脉曲张，且在这一群体中比在普通人群中更为常见。在处理男性因素不育症的临床医生中，对于精索静脉曲张是否会改变自然受孕的概率和/或生育治疗后的妊娠率及活产率，意见仍然存在分歧。近年来，关于是否应该治疗精索静脉曲张的争论愈演愈烈。这是因为人们不仅担心精索静脉曲张对传统精液参数的影响，还担心它们在细胞水平上可能产生的潜在影响（即使传统精液参数在正常参考范围内，循环活性氧（ROS）增加也会导致精子DNA碎片化）。有人认为，治疗精索静脉曲张可能会改善精液参数、自然受孕以及体外受精（IVF）或卵胞浆内单精子注射（ICSI）治疗后的受精率和妊娠率。在精液参数不理想的情况下，ICSI仍可用于辅助生殖治疗（ART）。然而，它是一种侵入性且昂贵的技术，对后代可能有潜在的不良影响。据我们所知，目前尚无随机对照试验比较精索静脉曲张治疗与立即使用ICSI对妊娠率的临床/成本效益。以往的模型研究年代久远，没有考虑到当前的实践和趋势，如女性年龄增长和受孕时间。患者有时收到的相互矛盾的建议，挑战了我们对循证医学实践的承诺。解决这一争议的唯一方法是进行一项有足够样本量的随机试验，评估精索静脉曲张治疗后的临床和成本效益以及受孕时间，并将其与未治疗组进行比较。
