The percutaneous embolization of varicocele requires which selective catheterisation of the internal spermatic vein(s) followed by its (their) occlusion with either a sclerosant or solid embolic devices came in for discussion at the GEST 2012 US meeting.
In his talk on “Tips for practice building”, Lindsay Machan, Vancouver, Canada, told delegates that the major difficulty of setting up a practice in many countries was the inability to get referrals. “Urologists are by their own societies’ position statements stating that varicocoele embolization is a long, complex procedure with high technical failure and recurrence rates. So it is important to start by considering the source of referral—begin by solving problems for the clinician and build their confidence in the procedure. It is also important to raise the technical success of the procedure and lower recurrences,” he said. “Do not start by competing directly with the urologist, rather involve urologists, infertility specialists and paediatricians for specific patients,” he said.
Machan noted that the indications for embolization were infertility coupled with appropriate semen abnormalities, groin pain and recurrence post surgery. “Recurrence is a problem for the urologist. Paediatricians see but cannot treat adolescent varicocoeles. The procedure can also be used to improve the outcomes of assisted reproductive techniques, which could aid infertility clinics,” he added.
Marc Schiffman, New York, USA, stated that ultrasonography currently represented the imaging technique of choice for the diagnosis of varicocoleles and their post-procedural follow-up due to its widespread availability, high reproducibility, low cost, and the absence of adverse effects. “The modality is, however, limited by a lack of standardisation in technique and reporting standards, and more work is needed in delineating the optimal prognostic value for this modality in varicocoele treatment,” he noted.
Then, Jacob Cynamon, New York, USA, speaking on the topic, “Does the evidence support treatment of varicoceles for infertility?” said: “Male factor fertility either alone or with female factors is believed to be a causal factor in as many as 50% of infertile couples.
Varicocoeles present the most common attributed cause of male infertility. Yet, 8
5% of men with varicocoeles in population-based studies have fathered children.”
Cynamon noted that with varicocoele embolization, semen analysis clearly improved and pregnancy rates could improve. He said that in vitro fertilisation was expensive and in vitro fertilisation pregnancy rates could improve with varicolectomy, thus decreasing the cost of in vitro fertilisation. “So clearly, adult males that fit the American Society for Reproductive Medicine guidelines (2008) guidelines should be treated. But the question still remains about which adolescents should be treated.”
Then, Ricardo Garcia-Monaco, Buenos Aires, Argentina, who was presenting on embolization vs. surgery for varicocoele told delegates: “The ideal method of varicocoele treatment remains a controversial issue. Each technique has merits and disadvantages.
Conflicting results have been achieved in different studies and the choice of treatment should take into account patient choice, but is mainly influenced by local policy and/or exp
He summarised the advantages of embolization as a bilateral treatment in the same session that was better tolerated than surgery with return to normal activity in 24–48hrs. “However there is uncommon physician referral to interventional radiology, except in the case of varicocoele recurrence,” he noted.
Garcia-Monaco pointed out that there were no randomised controlled trials that compared the various techniques to identify the best method for the treatment of varicoele in infertile men.
He said there was a general belief in the medical community that both embolization and surgery result in similar rates of improvement in semen parameters and successful pregnancy outcomes in infertile men.
“The major advantage of embolization is the absence of complications such as hydrocoele and a faster recovery, which are now matched by microsurgery,” he said.