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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Impact of surgical varicocele repair on pregnancy rate in subfertile men with clinical varicocele and impaired semen quality: a meta-analysis of randomized clinical trials

KH Kim, JY Lee, DH Kang, H Lee, JT Seo, and KS Cho.

Review published: 2013.

Link to full article: [PMC free article: PMC3806996]

CRD summary

This review concluded that varicocelectomy was effective for men with a varicocele and impaired semen quality, who were from couples with otherwise unexplained subfertility. Limited information about the included trials, the relatively few data, and the risks of bias, make the reliability of this conclusion uncertain. The authors' recommendation for a large properly conducted randomised controlled trial is justified.

Authors' objectives

To evaluate surgical varicocele repair for the treatment of male subfertility.

Searching

PubMed and EMBASE were searched for relevant publications up to 31st December, 2012. Additional studies were sought from reference lists. Search terms were reported.

Study selection

Randomised controlled trials (RCTs) comparing partner pregnancy outcomes, between treated and control groups, after surgical varicocele repair in men from couples with otherwise unexplained subfertility, were eligible for inclusion.

The participants in the included trials had a clinical or subclinical varicocele that was or was not palpable, abnormal semen analysis, or both. Control participants received no treatment, delayed surgery or clomiphene citrate. Surgical approaches varied across trials.

Two reviewers applied the inclusion criteria, with disagreements resolved by discussion or by arbitration.

Assessment of study quality

Trial quality was assessed using the Cochrane risk of bias tool, which evaluates the adequacy of randomisation, allocation concealment, blinding, data collection, and outcome reporting. Two reviewers independently assessed the trials.

Data extraction

The data were extracted to calculate odds ratios and 95% confidence intervals for pregnancy outcomes. The authors did not state how many reviewers extracted the data.

Methods of synthesis

Heterogeneity was tested and quantified using Cochran's Q and Ι²; heterogeneity was considered to be present if Cochran's Q was statistically significant (p<0.10) or if Ι² exceeded 50%. In the absence of statistical heterogeneity, the odds ratios and 95% confidence intervals were pooled using a fixed-effect model, otherwise a random-effects model was used.

Publication bias was assessed using the Begg-Mazumdar and Egger tests, in conjunction with funnel plots.

Results of the review

Seven RCTs (610 participants) were included. All were at a high risk of bias due to the absence of blinding; most of the other criteria were unclear.

Random-effects meta-analysis showed a statistically non-significant pooled odds ratio favouring surgical varicocele repair over control (1.90, 95% CI 0.77 to 4.66; Ι²=64.1%).

A fixed-effect subgroup meta-analysis of only RCTs of men with clinical varicocele and impaired semen quality (three trials) showed a statistically significant pooled odds ratio favouring surgical varicocele repair over control (4.15, 95% CI 2.31 to 7.45; Ι²=20.4%).

There was no evidence of publication bias.

Authors' conclusions

Varicocelectomy for male subfertility was effective for men with a varicocele and impaired semen quality, who were from couples with otherwise unexplained subfertility.

CRD commentary

This review identified and analysed RCTs evaluating the effects of varicocele repair on partner pregnancy outcomes, using standard methods. Attempts were made to minimise bias in the selection and appraisal of relevant published literature, and the results were combined using broadly appropriate statistical techniques.

The authors main conclusions were based on a subgroup of three RCTs with only 312 participants with clinical varicocele and impaired semen quality. These three trials appear to have used different surgical techniques, but no further information was available on the participants, outcomes other than pregnancy rates, and length of follow-up. These trials also appear to have been at risk of bias.

Given these limitations, the authors' recommendation for a large properly conducted RCT appears to be justified. The reliability of their conclusion on the effectiveness of varicocelectomy is less certain.

Implications of the review for practice and research

Practice: The authors stated that surgical repair should be offered as the first treatment for clinical varicocele in subfertile men.

Research: The authors stated that there was a need for large, properly conducted, RCTs of varicocele treatment in men with impaired semen quality, from couples with otherwise unexplained subfertility. These trials should evaluate microsurgical varicocelectomy, using the outcome of spontaneous pregnancy.

Funding

Not stated.

Bibliographic details

Kim KH, Lee JY, Kang DH, Lee H, Seo JT, Cho KS. Impact of surgical varicocele repair on pregnancy rate in subfertile men with clinical varicocele and impaired semen quality: a meta-analysis of randomized clinical trials. Korean Journal of Urology 2013; 54(10): 703-709. [PMC free article: PMC3806996] [PubMed: 24175046]

Indexing Status

Subject indexing assigned by CRD

AccessionNumber

12013063868

Database entry date

16/05/2014

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 24175046

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