Potential role of imaging in assessing harmful effects on spermatogenesis in adult testes with varicocele

Table 1 Sarteschi classification

Grade	Characteristics
1	Venous reflux at the emergence of the scrotal vein only during the Valsalva maneuver; hypertrophy of the venous wall without stasis
2	Supratesticular reflux only during the Valsalva maneuver; venous stasis without varicosities
3	Peritesticular reflux during the Valsalva maneuver; overt varicocele with early stage varices of the cremasteric vein
4	Spontaneous basal reflux that increases during the Valsalva maneuver; possible testicular hypotrophy, overt varicocele, varicosities in the pampiniform plexus
5	Spontaneous basal reflux that does not increase during the Valsalva maneuver; testicular hypotrophy, overt varicocele, varicosities in the pampiniform plexus

Table 2 Chiou et al[47] classification (total score of ≥ 4 defined as varicocele)

Characteristics	Grade
Maximum vein diameter (mm)
< 2.5	0
2.5-2.9	1
3-3.9	2
≥ 4	3
Plexus/sum of diameter of veins
No plexus identified	0
Plexus (+) with sum diameter < 3 mm	1
Plexus (+) with sum diameter 3-5.9 mm	2
Plexus (+) with sum diameter ≥ 6 mm	3
Change of flow velocity on Valsalva maneuver
< 2 cm/s or duration < 1 s	0
2-4.9	1
5-9.9	2
≥ 10	3
Total score	0-9

Table 3 Summary of recommendations for the diagnosis and treatment of varicoceles

	ASRM/SMRU	AUA	EAU
Guideline title	Report on varicocele and infertility: A committee opinion	The optimal evaluation of the infertile male: AUA best practice statement	Guidelines on male infertility
Infertile male evaluation	Medical and reproductive history, physical examination and at least two semen analyses	Complete medical history, physical examination by a urologist or other specialist in male reproduction and at least two semen analyses	Medical history and physical examination, including semen analysis: One semen analysis is sufficient if normal, two will be performed if the first one is abnormal based on WHO 2010 criteria
Optimal method to detect varicocele	Physical examination; varicoceles graded, 1 to 3	Physical examination; varicoceles graded, 1 to 3	Physical examination; varicoceles graded, 1 to 3
Role of scrotal US	For inconclusive physical examination	Indicated in those patients in whom physical examination is difficult or inadequate or a testicular mass is suspected	Used to confirm presence of varicocele identified on physical examination
Indications for treatment of varicocele	If the male partner of a couple attempting to conceive has a varicocele, treatment should be considered if most or all the following are met: clinically palpable varicocele; abnormal semen parameters; known infertility; female partner has normal fertility or a potentially treatable cause of infertility; time to conception is not a concern. An adult male who is not currently attempting to achieve conception but has a palpable varicocele, abnormal semen analyses and a desire for future fertility, and/or pain related to the varicocele is also a candidate for varicocele repair	Not stated	Varicocele repair may be effective in men with abnormal semen analysis, a clinical varicocele and otherwise unexplained infertility of duration > 2 yr
Contraindications to treatment	Patients with either normal semen analysis, isolated teratozoospermia, or a subclinical varicocele; and, if IVF or IVFICSI is otherwise required for the treatment of a female factor infertility	Not stated
Method of treatment	There are two types of varicocele management, surgical repair and percutaneous embolization. Multiple types exist within each category. None of these has been proven superior to the others in its ability to improve fertility, although there are differences in recurrence rates with microsurgical subinguinal varicocelectomy having the lowest recurrence rates	Not stated	Reviews all types of treatment within guidelines and provides complication and recurrence rates of each, without specific recommendations

ASRM: American Society of Reproductive Medicine; SMRU: Society of Male Reproduction and Urology; AUA: American Urological Association; EAU: European Association of Urology; WHO: World Health Organization; IVF: In vitro fertilization; ICSI: Intracytoplasmic sperm injection.