Society For Pediatric Urology

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How many semen analyses are needed to evaluate the adolescent with a varicocele to determine a plan for intervention?
Vinaya Vasudevan, M.D., Lane S. Palmer, M.D., F.A.C.S, F.A.A.P.
Cohen Children's Medical Center at Zucker/Hofstra School of Medicine, Northwell Health Systems, New Hyde Park, NY, USA.

Background: Semen analysis (SA) remains the most direct test for assessing fertility potential in adolescents with a varicocele, and thus offers great importance in management decisions. We sought to assess the predictive value of a single SA for decreased TMC and the need for subsequent repeats in these patients.
Methods: A retrospective review of all Tanner 5 adolescent males with varicoceles with a minimum of 2 SA performed within 3 months and prior to any intervention managed by a single surgeon. Clinical and demographic data were reviewed, in addition to interventions undertaken. SA were performed at a single infertility center after a period of abstinence. WHO criteria for normal semen analysis parameters in adults including total volume (TV), sperm count (SC), motility, morphology, and total motile count (TMC). According to the new WHO guidelines for normal TMC, a TMC >15million/mL was considered normal. Descriptive statistics, paired T tests, and regression analyses were performed.
Results: Eighty-six adolescent males met inclusion criteria. The mean age at diagnosis was 15.6 years (range 12-22), while the time of first SA was 17.5 years (range 16-21). The varicocele size was Grade 1 in 2 patients (1.9%), Grade 2 in 60 patients (57%), and Grade 3 in 42 patients (40%) at the time of SA. On average, the repeat SA was obtained within 1.13 months of the prior SA. The average number of SA obtained between patients undergoing watchful waiting and surgical ligation was not significantly different (p = 0.613).
On a multivariate analysis including grade, age, and TMC, an abnormal TMC on the first SA was predictive of an abnormal result on final TMC (p = 0.0003) and of the need for surgery (p = 0.009). Further, an abnormal TV (p = 0.00009), SC (p =0.002), or motility (p = 0.021) were all predictive of an abnormal result on the following SA. An abnormal SC (p = 0.000006) or motility (p = 0.0005) were both predictive of the need for surgery. Abnormal morphology was not predictive of abnormal TMC on the following semen analysis or of the need for surgery.
Conclusions: Often, an abnormal result on an initial semen analysis after completion of puberty is predictive of an impaired TMC on repeat and may intimate the need for future surgical ligation in patients with PV. Confirmatory SA seldom yields new results or provides additional diagnostic value, as the first SA often has strong predictive value in determining the results of future SA or of the need for surgery regardless of varicocele grade.

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