A closer look: sperm analysis and clinical outcomes of microscopic and loupe-assisted varicocele repair in male infertility due to moderate-to-severe varicocele.

[PURPOSE] The aim of the study was to compare the clinical outcomes, sperm parameters, and complications of loupe-assisted and microscopic varicocele repair in patients with infertility due to moderate-to-severe varicocele.

[METHODS] We included all male individuals over 18 years of age who underwent inguinal varicocele repair at our center due to infertility. Subjects with azoospermia, genetic abnormalities such as Kallmann syndrome, incomplete medical records, or those lost to follow-up were excluded from the study. Patients were divided into two groups based on the magnification tool used (microscope or loupe). Follow-ups were conducted at 3 months and 1 year post-surgery. Sperm parameters, pregnancy rates, and surgical complications were recorded to compare the efficacy of the magnification tools. The Improvement Index for sperm parameters was calculated by dividing the difference between the post-operative and pre-operative parameters by the pre-operative parameter. An Improvement Index above 0.5 was considered a good outcome.

[RESULTS] Out of 104 patients, 58 underwent loupe-assisted and 46 underwent microscopic varicocele repair. Sperm concentration and progressive motility increased significantly in the semen analyses at three months and one year post-operation compared to pre-operative semen analyses. However, increases in sperm morphology were not statistically significant in either follow-up semen analysis. An Improvement Index greater than 0.5 (indicating a good outcome) was observed in 35.3%, 34.1%, and 15.2% of patients for sperm concentration, progressive motility, and morphology, respectively, after 3 months, and 38.9%, 43.4%, and 22.4% after 1 year. Nonetheless, there were no significant differences in the Improvement Index of sperm parameters between the two magnification methods. The operative duration was significantly longer with microscopic magnification (median of 70.0 [20.0] minutes vs. 45.0 [20.0] minutes) (p value < 0.001). Conversely, the pregnancy rates were 34.5% (20 patients) in the loupe-assisted group and 37.0% (17 patients) in the microscopic group, which was not significantly different (p value: 0.794). Similarly, the rate of complications was not significantly different, with 5 patients (10.9%) experiencing complications (4 hydroceles and 1 wound infection) in the microscopic group compared to 4 patients (6.9%) (3 hydroceles and 1 wound infection) in the loupe-assisted group (p value: 0.504).

[CONCLUSIONS] The current study's results indicate that the clinical outcomes, sperm parameters, and complications associated with loupe-assisted varicocele repair are comparable to those of microsurgical varicocele repair, which is considered the gold standard. We suggest conducting prospective studies to assess whether loupe-assisted varicocele repair is a safe alternative, especially in centers with limited or no access to surgical microscopes.