The Effect of Varicocelectomy on Assisted Reproductive Technique Indications and Outcomes based on Kruger Strict Morphology Test: a Randomized Clinical Trial

Document Type : Original Article


1 Associate Professor of Urology, Physiology Research Center, Kerman Medical Sciences University, Kerman, Iran

2 Urology Resident, Kerman Medical Sciences University, Kerman, Iran

3 Anesthesia Department, Physiology Research Center, Kerman Medical Sciences University, Kerman, Iran


Background: A significant percent of infertile varicocele patients remained infertile after varicocelectomy and finally most of them refer for assisted reproductive technique (ART) procedures as intra uterine insemination (IUI), in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). In order to achieve the best results, more strict and accurate standards for assessment of sperm parameters, as Kruger standards, are required.
Objective:The main goal of this study was to evaluate the efficacy of varicocelectomy onimproving selection of ARTs on the base of Kruger strict morphology test.
Method: In a randomized clinical trial study, the results of sperm parameters analysis by Kruger strict morphology test were compared between a group of 67 infertile operated patients and a group of 71 matched no operated men in one-year duration.
Results: The selection of better ART levels (IUI vs. ICSI) after varicocelectomy was higher in the operated group than controls (p <0.05). Pregnancy rates (achieving full-term pregnancy by natural cycle intercourse), after one year, were respectively 53.84% and 42.25% in the two groups of operated and non-operated (p=0.082).
Conclusion: According to our results, varicocelectomy improves the ART level selection and also may improve pregnancy success rates (both by natural cycle intercourse and ART procedures).


  1. Belay RE, Huang GO, Shen JK, Ko EY. Diagnosis of clinical and subclinical varicocele: how has it evolved? Asian J Androl 2016; 18 (2):182-5.
  2. Kimura M, Nagao K. Role of varicocele repair for male infertility in the era of assisted reproductive technologies. Reprod Med Biol 2014; 13 (4):185-92.
  3. Ketabchi AA, Salajegheh S. The effects of acupuncture treatment in infertile patients with clinical varicocele. Nephro-Urology Monthly 2018; 10 (6):e65451.
  4. Masson P, Brannigan RE. The varicocele. Urol Clin North Am 2014; 41 (1):129-44.
  5. Pauroso S, Di Leo N, Fulle I, Di Segni M, Alessi S, Maggini E. Varicocele: ultrasonographic assessment in daily clinical practice. J Ultrasound 2011; 14 (4):199-204.
  6. Sinanoglu O, Eyyupoglu SE, Ekici S. Ipsilateral testicular catchup growth rate following microsurgical inguinal adolescent varicocelectomy. The Scientific World Journal 2012; 2012:356374.
  7. Agarwal A, Sharma R, Harlev A, Esteves SC. Effect of varicocele on semen characteristics according to the new 2010 World Health Organization criteria: a systematic review and meta-analysis. Asian J Androl. 2016;18 (2):163-70.
  8. Santana VP, Miranda-Furtado CL, de Oliveira-Gennaro FG, Dos Reis RM. Genetics and epigenetics of varicocele pathophysiology: an overview. J Assist Reprod Genet. 2017;34 (7):839-847. Kantartzi PD, Goulis Ch, Goulis GD, Papadimas I. Male infertility and varicocele: myths and reality. Hippokratia 2007; 11 (3):99-104.
  9. Demirtola A, Ozen IO, Ozturk GS, Vural IM, Ercan S, Kale N, et al. The effects of varicocele and its surgical correction on vas deferens motility. Pediatr Surg Int 2008; 24 (3):319-23.
  10. Zhang QY, Qiu SD, Ma XN, Yu HM, Wu YW. Effect of experimental varicocele on structure and function of epididymis in adolescent rats. Asian J Androl 2003; 5 (2):108-12.
  11. Will MA, Swain J, Fode M, Sonksen J, Christman GM, Ohl D. The great debate: varicocele treatment and impact on fertility. Fertil Steril 2010; 95 (3):841-52.
  12. Lipshultz LI, Corriere JN Jr. Progressive testicular atrophy in the varicocele patient. J Urol 1977; 117 (2):175-6.
  13. Fariss BL, Fenner DK, Plymate SR, Brannen GE, Jacob WH, Thomason AM. Seminal characteristics in the presence of a varicocele as compared with those of expectant fathers and prevasectomy men. Fertil Steril 1981; 35 (3):325-7.
  14. Chen SS, Chen LK. Predictive factors of successful varicocelectomy in infertile patients. Urol Int 2011; 86 (3):320-4.
  15. Baazeem A, Belzile E, Ciampi A, Dohle G, Jarvi K, Salonia A, et al. varicocele and male factor infertility treatment: a new metaanalysis and review of the role of varicocele repair. Eur Urol 2011; 60 (4):796-808.
  16. Mohamed EE, Gawish M, Mohamed A. Semen parameters and pregnancy rates after microsurgical varicocelectomy in primary versus secondary infertile men. Human Fertility 2017; 20 (4):293-6.
  17. Mangoli V, Dandekar S, Desai S, Mangoli R. The outcome of ART in males with impaired spermatogenesis. J Hum Reprod Sci 2008; 1 (2):73-6.
  18. Keck C, Gerber-Schäfer C, Breckwoldt M. Intrauterine insemination as first line treatment of unexplained and male factor infertility. European Journal of bstetrics & Gynecology and Reproductive Biology 1998; 79 (2):193-7.
  19. Fang C, Tang J, Huang R, Li LL, Zhang MF, Liang XY. Comparison of IVF outcomes using conventional insemination and ICSI in ovarian cycles in which only one or two oocytes are obtained. J Gynecol Obstet Biol Reprod (Paris) 2012; 41 (7):650-6.
  20. Menkveld R. Clinical significance of the low normal sperm morphology value as proposed in the fifth edition of the WHO Laboratory Manual for the Examination and Processing of Human Semen. Asian J Androl 2010; 12:47–58.
  21. Check JH, Bollendorf A, Wilson C, Summers-Chase D, Horwath D, Yuan W. A retrospective comparison of pregnancy outcome following conventional oocyte insemination vs intracytoplasmic sperm injection for isolated abnormalities in sperm morphology using strict criteria. J Androl 2007; 28 (4):607-12.
  22. Sengupta P. Reviewing reports of semen volume and male aging of last 33 years: From 1980 through 2013. Asian pac j reprod 2015; 4 (3):242-6.
  23. O'Brien JH, Bowles B, Kamal KM, Jarvi K, Zini A. Microsurgical varicocelectomy for infertile couples with advanced female age: natural history in the era of ART. J Androl 2004; 25 (6):939-43.
  24. Cho KS, Seo JT. Effect of varicocelectomy on male infertility. Korean J Urol 2014; 55 (11):703-9.
  25. Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM. Does varicocele repair improve male infertility? an evidence‑based perspective from a randomized, controlled trial. Eur Urol 2011; 59 (3):455-61.
  26. Al-Ghazo MA, Ghalayini IF, al-Azab RS, Bani-Hani I, Daradkeh MS. Does the duration of infertility affect semen parameters and pregnancy rate after varicocelectomy? a retrospective study. Int Braz J Urol 2011; 37 (6):745-50.
  27. Kibar Y, Seckin B, Erduran D. The effects of subinguinal varicocelectomy on kruger morphology and semen parameters. J Urol 2002; 168 (3):1071-4.
  28. Esteves SC, Oliveira FV, Bertolla RP. Clinical outcome of intracytoplasmic sperm injection in infertile men with treated and untreated clinical varicocele. J Urol 2010; 184 (4):1442-6.
  29. Nistal M, González-Peramato P, Serrano A, Regadera J. Physiopathology of the infertile testicle. Etiopathogenesis of varicocele. Arch Esp Urol 2004; 57 (9):883-904. [In Spanish].
  30. Miyaoka R, Esteves SC. A critical appraisal of the role of varicocele in male infertility. Adv Urol 2012; 2012:597495.
  31. Werthman P, Wixon R, Kasperson K, Evenson DP. Significant decrease in sperm deoxyribonucleic acid fragmentation after varicocelectomy. Fertil Steril 2008; 90 (5):1800-4.
  32. Schlegel PN. Is assisted reproductive the optimal treatment for varicocele-associated male infertility? A cost-effectiveness analysis. Urology 1997; 49:83–90.