3. VARICOCELE  Most common identifiable pathology in infertile men.  Affects 35% - 40% of men presenting for infertility evaluation.

4.  Management of male-factor infertility with clinical varicocele and abnormal semen parameters: Varicocele repair Assisted Reproductive Technologies (ARTs) ○ Intrauterine Insemination (IUI) ○ In Vitro Fertilization with Intracytoplasmic Sperm Injection (IVF/ICSI) Observation

5. OBJECTIVES  Assess pregnancy outcomes of two cohorts of infertile men with bilateral varicoceles: Bilateral varicocelectomy No surgery

7.  Retrospective review of 610 consecutive infertile couples with clinical varicoceles.  All men had: one year or more of infertility bilateral clinically palpable varicocele (examined by same investigator – AZ) abnormal semen parameters  Couples with subclinical or unilateral clinical varicoceles, tubal obstruction or ovulatory failure excluded.

8.  Couples counseled about treatment options (observation, varicocelectomy & ARTs)  All microsurgical varicocelectomies performed by same surgeon (AZ).

9.  Outcome measures: Pregnancy rates (natural and assisted) Changes in semen parameters Utilization of ARTs

11.  Total of 610 consecutive infertile men with a clinical varicocele  238 (39%) infertile men with bilateral clinical varicoceles  157 (66%) chose bilateral varicocelectomy Surgical (SUR) group  81 (34%) men chose not to have surgery Non-surgical (NON-SUR) group.

12. MEAN (±SD) BASELINE CLINICAL PARAMETERS SURNON-SURP-value Male age 35.8  5.736.0  5.1 NS Female age 34.0  4.432.9  4.7 NS Duration of infertility (months) 29.5  21.733.3  37.6 NS Percentage with secondary infertility 20%27%NS Left testicular volume (ml) 13.8  4.216.0  3.1 <0.0001 Right testicular volume (ml) 14.7  4.317.1  3.1 <0.0001

13. MEAN (±SD) BASELINE CLINICAL PARAMETERS SURNON-SURP-value Serum FSH (IU/ml) 6.4  8.65.4  4.2 NS Serum LH (IU/ml) 4.6  6.53.8  2.6 NS Semen volume (ml) 3.1  1.53.5  2.5 NS Sperm concentration (x 10 6 /ml) 20.8  24.326.6  29.4 NS Sperm motility (% motile) 26.1  17.235.5  19.8 0.0003 Sperm morphology (% normal forms) 40.4  21.831.5  14.8 0.004

14. MEAN (± SD) SUR GROUP SEMEN PARAMETERS Pre-OPPost-OPP-value Semen volume (ml) 3.1  1.5 3.2  1.5 NS Sperm concentration (x10 6 /ml) 20.8 ± 24.327.3 ± 28.10.008 Motile sperm (%) 26.1  17.234.1  19.9 <0.0001 TMC (x10 6 ) 17.0  24.736.4  49.6 <0.0001 Sperm morphology (% normal) 40.4  21.840.1  22.1 NS

15.  Pregnancy outcome and ART utilization data available for: 67.5% (106/157) of SUR group 64% (52/81) of NON-SUR group.

16. MEAN (±SD) BASELINE CLINICAL PARAMETERS IN COUPLES WITH PREGNANCY OUTCOME DATA SURNON-SURP-value Semen volume (ml) 3.1  1.63.6  2.9 NS Sperm concentration (x 10 6 /ml) 20.1  23.026.1  30.1 NS Sperm motility (% motile) 25.0  16.432.3  20.2 0.018 TMC (x 10 6 ) 16.1  20.739.1  58.6 0.0006 Sperm morphology (% normal) 37.7 ± 22.830.2 ± 12.4NS Follow-up (months) 39.0 ± 23.840 ± 14NS

17. PREGNANCY & ART UTILIZATION RATES IN COUPLES WITH PREGNANCY OUTCOME DATA SURNON-SURP-value Natural pregnancy rate 47%23%0.0061 Natural + ART pregnancy rate 60%50%NS IUI Utilization22%35%NS ICSI Utilization23%46%0.0046 Overall ART utilization (IUI + ICSI) 32%62%0.0012

19.  Bilateral varicocele repair, when compared to non-surgical management, was associated with: Significant improvements in semen parameters Significant increase in natural pregnancy rate Significantly less overall ART utilization

20.  For bilateral clinical varicoceles, microsurgical repair is a favourable option for treating couples with male factor infertility.