ART and varicocele repair in men with non-obstructive azoospermia (NOA):
Although the use of ART is inevitable in men with spermatogenic deficiency, varicocele repair can recover healthy sperm in the ejaculate of infertile men with NOA and clinical varicocele, and thus lower the need for ART and the associated costs . The chance of sperm being present in the ejaculate is related to testicle histology. Whilst the chance of recovery increases amongst men with hypospermatogenesis and late maturation arrest, there is no recovery of the semen parameters in men with early maturation arrest or Sertoli-cellonly histology [32,33]. Schlegel and Kaufmann  reported that <10% of men with NOA with varicocele had an adequate number of motile sperms for ICSI after varicocele repair, but there was no significant difference in sperm acquirement ratios during testicular sperm extraction (TESE) when these patients were compared to a group without varicocelectomy. Current studies show that sperm acquirement ratios are higher in patients with NOA after varicocele repair [35,36]. Studies have determined that there is intermittent sperm in the ejaculates of 5–35% of patients with NOA who go without any treatment [34,37,38]. However, the presence of sperm rate in the ejaculate of NOA patients after varicocelectomy was found to be between 19% and 22% [34,39]. The gradual regression of spermatogenesis and the reversal to azoospermia were reported at a rate of 55.5% in patients with NOA at 1 year after varicocelectomy. This shows that varicocele repair does not have a long-term positive effect in patients with NOA . Spermatogenesis is recovered in a minority of men after varicocelectomy, and a significant number of these lose their spermatogenic abilities again in the long term. Thus, it is suggested to freeze and retain the sperm after the initial recovery after varicocelectomy . Varicocele repair before ART can allow for successful pregnancy in such individuals and decrease the costs associated with pregnancy by lowering the need for ICSI. However, ART is necessary in most patients with NOA, as the chance of sperm in the ejaculate after varicocele repair is low. Therefore, varicocele repair may not be a cost-effective solution for these patients.
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