A cost outcome study of varicocoele embolisation and future pregnancy in an Australian public hospital setting.

INTRODUCTION: Varicocoele is commonly encountered in males with infertility. Studies have shown that varicocoele repair (surgery or embolisation) can improve the rate of subsequent pregnancy. In Australia, there have been no studies assessing the cost of varicocoele embolisation and current practice is based on international data. This study aimed to assess the cost of varicocoele embolisation and estimate the treatment cost per pregnancy. METHODS: Retrospective cost-outcome study of patients treated by embolisation between January 2018 and 2023. A bottom-up approach was used to calculate procedure costs whereas a top-down approach was used to calculate costs for all other patient services, including direct and indirect costs. To calculate cost per pregnancy, costs were adjusted according to existing published data on the rate of pregnancy after embolisation. RESULTS: Costing data from 18 patients were included, of median age 33.5 years (range 26-60) and median varicocoele grade 2.5 (range 1-3). All patients had unilateral treatment, most commonly via right internal jugular (16 patients, 89%) and using a 0.035″ system (17 patients, 94%). The median cost for the entire treatment including procedural, non-procedural, ward and peri-procedural costs was AUD$2208.10 (USD$1405 or EUR€1314), range AUD$1691-7051. The projected cost to the healthcare system per pregnancy was AUD$5387 (USD$3429 or EUR€3207). CONCLUSION: Total varicocoele embolisation cost and the cost per-pregnancy were lower than for both embolisation and surgical repair in existing international studies. Patients undergoing varicocoele treatment should have the option to access an interventional radiologist to realise the benefits of this low-cost pinhole procedure.

Cost-effectiveness of varicocele surgery in the era of assisted reproductive technology.

The advent of innovative techniques for addressing infertility has made for exciting times in the arena of andrology. The success of microTESE for retrieving sperm has enabled azoospermic men to have the opportunity to father biological children when it was previously impossible. The ability to offer a variety of assisted reproductive techniques that includes intracytoplasmic sperm injection has opened the door for couples with male factor infertility who were otherwise untreatable. With the multitude of options available to infertile couples, however, comes an unsurprising degree of controversy regarding what treatments should be offered and when. Complicating the picture is the question of if and when varicocele repair should be undertaken, and the financial implications of the treatment decisions that are made. The infertile couple with varicocele warrants careful consideration. The overall efficacy of varicocele repair as well as cost-effectiveness of repair compared to immediate microTESE in azoospermic men and assisted reproductive technology in men with suboptimal semen parameters will be reviewed.

[The varicocele: the proper therapy for the proper patient]. / Il varicocele: la "giusta" terapia per il "giusto" paziente.

Varicocele is present in 15% to 20% of the general population, but in approximately 35% to 40% of males presenting for an evaluation of their infertility. Indeed it is well known that varicocele can cause testicular damage and infertility. No evidence indicates a varicocele treatment in infertile men who have normal semen analysis or in men with subclinical varicocele. In this situation, varicocelectomy cannot be recommended. Varicocele repair may be effective in men with subnormal semen analysis, a clinical varicocele and otherwise unexplained infertility, but we need further randomized studies to confirm that this subgroup of infertile couples will benefit from treatment. There is no doubt about the standard indications of varicocelectomy, but recent literature seems to go towards new indications of varicocele repair. The aim of this review is to give a look at the literature to analyze the proper indications to varicocelectomy for the proper patient.

Varicocele repair for nonobstructive azoospermia.

PURPOSE OF REVIEW: To evaluate the role of varicocelectomy in the management of patients with varicoceles and nonobstructive azoospermia and to review predictors of successful outcomes. RECENT FINDINGS: Several small, retrospective, noncontrolled studies have documented return of sperm to the ejaculate in up to 56% of men with nonobstructive azoospermia (NOA) following varicocele repair. Additionally, a recent meta-analysis has reported a 6% spontaneous pregnancy rate in amongst NOA patients who underwent varicocele repair, regardless of surgical technique. Although these observations are promising, evidence for whether or not varicocele repair significantly improves spermatogenesis within an impaired testicle is conflicting. No clear predictors of success following varicocele repair have been identified, but a certain level of spermatogenesis on testicular biopsy appears to be necessary for a desirable outcome after varicocele repair. SUMMARY: The role of varicocelectomy for the treatment on NOA is controversial. Prospective, controlled studies are needed in order to define the true benefit of varicocele repair in men with NOA, in terms of improvement in semen parameters, testicular sperm retrieval rates, and pregnancy outcomes.

Comparing three different surgical techniques used in adult bilateral varicocele.

INTRODUCTION: Varicocele is a common disease in adult men that can be treated with one of several surgical methods. Each technique has advantages and disadvantages, and conflicting results have been obtained by different studies. To evaluate the most effective surgical techniques used in adult bilateral varicocele, including minimally invasive procedures, we compared the outcomes of three common surgical approaches in this prospective randomized study. METHODS: The study included 153 patients with bilateral varicoceles who underwent varicocelectomy. These patients were randomly divided into three equal groups according to surgical approach used - open inguinal, retroperitoneal or laparoscopic. The assessment included operative time, length of hospital stay, clinical outcome and, in cases of infertility, semen analysis. The mean follow-up was 12 months (range, 8 to 15 months). RESULTS: The operative time and hospital stay in the laparoscopic group were significantly shorter than in the other groups (P < 0.01). Of the 51 cases in each group, there were seven cases (13.73%) of recurrence in the open inguinal group, six cases (11.76%) in the retroperitoneal group, and one case (1.96%) in the laparoscopic group. This lower rate of recurrence was statistically significant in the laparoscopic group (P < 0.05). Among the three groups, comparisons between preoperative and postoperative semen parameters showed visible improvements in sperm concentration and motility (P < 0.01), but there were no significant differences between the three groups for postoperative changes in semen parameters (P > 0.05). CONCLUSIONS: Compared with open inguinal and retroperitoneal varicocelectomy, laparoscopic varicolerectomy offers the best outcome.

Laparoendoscopic single-site varicocele repair in adolescents-initial experience at a single institution.

BACKGROUND AND PURPOSE: Laparoendoscopic single-site (LESS) varicocele repair is a modification of standard laparoscopic varicocele repair that uses a single port. We describe our initial experience with LESS varicocele repair. PATIENTS AND METHODS: During a 1-year period, all patients who presented for varicocele repair underwent LESS repair. We evaluated our initial experience by determining operative time, operative and postoperative complications, and overall cost of the procedure. RESULTS: A total of 11 adolescents underwent LESS varicocele repair. There were no intraoperative complications, and there were no conversions to open surgery or traditional laparoscopy. Estimated blood loss was minimal, and mean operative time was 66.9 minutes (range 48-91 min). The varicocele was corrected in all cases. During the 4 to 14 month follow-up, there was no recurrence, testis atrophy, or hernia in any patient. One subclinical hydrocele developed postoperatively that has not been repaired. CONCLUSION: Our experience with LESS varicocele repair in adolescents suggests it to be a safe and effective method for varicocele repair in adolescents.

[Laparoscopic and microsurgical varicocelectomy: comparison of the results].

Laparoscopic and microsurgical varicocelectomy were compared by clinical and cost efficacy results. Microsurgical subinguinal varicocelectomy was performed in 129 patients, laparoscopic - 167 patients. Median of the patients' age was 27 years (16-38 years). Median of follow-up in microsurgical operation was 26 months (13-60 months), in laparoscopic method - 62 months (28-71 months). By clinical criteria (time of surgical intervention, amount of analgetic drugs in the postoperative period, stay in hospital, rate of varicocele recurrence and postoperative complications), the results of microsurgical varicocelectomy proved significantly better than those of laparoscopic operations. The rate of all complications after microsurgical ligation of the testicular veins was 8 times less than after laparoscopic intervention, the rate of varicocele recurrence - 2.4 times less. Microsurgical operations were financially more effective (by 20%) than laparoscopic varicocelectomy. Thus, microsurgical varicocelectomy is more effective than laparoscopic one both clinically and financially.

Cost-benefit analysis of scrotal ultrasound in treatment of adolescents with varicocele.

PURPOSE: Varicoceles are a major cause of male factor infertility, although management of adolescent varicoceles is controversial. Most clinicians advocate repair if there is a persistent testicular size discrepancy of greater than 20%. Using previously published data, we performed a cost-benefit analysis of testicular ultrasound vs orchidometry to evaluate for this size difference. MATERIALS AND METHODS: We performed a PubMed search using the terms "adolescent varicocele," "ultrasound and varicocele," and "testis size and varicocele." Using the data from the relevant studies and Medicare reimbursement data from our region, we determined the cost of missing a persistent testicular size difference of greater than 20%. RESULTS: Approximately 25% of adolescents with varicocele have a persistent size discrepancy of greater than 20%. Approximately 40% of this group would be identified as having a size discrepancy with conventional orchidometry. The annual cost of ultrasound for every adolescent male with a varicocele would be $364 million if the imaging were done in an office based setting. If the testing were done at a hospital, the annual cost would be $795 million. The cost per case of missed persistent size discrepancy spanning 3 years is approximately $5,597 for office ultrasound and $12,226 for hospital ultrasound. CONCLUSIONS: There is limited evidence that adolescent varicocele repair improves paternity in adulthood. In an era of increasing health care costs the expense of ultrasound to evaluate for size discrepancy is significant and should be thoughtfully evaluated.

Percutaneous treatment of varicocele with microcoil embolization: comparison of treatment outcome with laparoscopic varicocelectomy.

Successful treatment of a testicular varicocele, which can result in scrotal pain and swelling as well as male subfertility, can be accomplished via operative ligation of the varicocele or interventional treatment with coil embolization of the testicular vein. This study compared the treatment outcome of percutaneous embolization treatment versus laparoscopic varicocelectomy in patients with symptomatic varicoceles. Patients with varicoceles undergoing either laparoscopic varicocelectomy or percutaneous coil embolization of the testicular vein during a recent 5-year period were analyzed. Treatment outcome and hospital costs of these two minimally invasive treatment modalities were compared. Forty-one patients underwent percutaneous coil embolization of the testicular vein, which were compared with a cohort of 43 patients who underwent laparoscopic varicocelectomy. Technical success in interventional and laparoscopic treatment was 95% and 100%, respectively. The mean operative time or procedural time was 63 +/- 13 minutes and 52 +/- 25 minutes for interventional and laparoscopic cohorts (not significant), respectively. Embolization treatment resulted in two recurrent varicoceles (4.8%) compared to one patient following laparoscopic repair (2.3%, not significant). Embolization treatment was associated with a lower complication rate than laparoscopic repair (9.7% vs 16.3%, p = .03). Regarding cost analysis, no significant difference in hospital cost was noted between the interventional or laparoscopic treatment strategies. Both laparoscopic varicocelectomy and coil embolization are effective treatment modalities for varicoceles. With lower treatment complication rates in the interventional treatment group, coil embolization of the testicular vein offers treatment advantage compared with laparoscopic repair in patients with varicoceles.

A decision analysis of treatments for nonobstructive azoospermia associated with varicocele.

OBJECTIVE: To examine the economic impact of initial treatments for varicocele-associated nonobstructive azoospermia, specifically varicocelectomy versus microsurgical testicular sperm extraction (TESE) with IVF/intracytoplasmic sperm injection (ICSI). DESIGN: Decision analytic model based on 1) outcomes data from Society for Assisted Reproductive Technology (SART) database and peer-reviewed literature and 2) costing data from Medicare Resource-Based Relative Value Scale and sampling of high volume US IVF centers. SETTING: Academic medical center. PATIENT(S): Simulation with a decision analytic model. INTERVENTION(S): Variation of successful spontaneous live delivery after varicocelectomy versus rate of successful live delivery after IVF/ICSI. MAIN OUTCOME MEASURE(S): Cost-effectiveness. RESULT(S): Microsurgical TESE was more cost effective than varicocelectomy. In 1999, initial treatment with microsurgical TESE was more cost effective ($65,515) than varicocelectomy ($76,878). Relative cost-effectiveness was unchanged in 2005: $69,731 versus $79,576. The cost-effectiveness of both treatments improved in relation to projections by inflation. Sensitivity analyses suggest that the relative cost-effectiveness of TESE versus varicocelectomy can only be changed with either substantial improvement in spontaneous live delivery rates after varicocelectomy or with deterioration in IVF success rates. CONCLUSION(S): Microsurgical TESE appears to be more cost effective than varicocelectomy for treatment of varicocele-associated nonobstructive azoospermia when indirect costs are considered. The cost-effectiveness of both treatments has improved with time. These results may be tailored with institution-specific data to allow more individualized results.

Two-trocar laparoscopic varicocelectomy: cost-reduction surgical technique.

OBJECTIVES: To describe the technique of two-trocar laparoscopic varicocelectomy and compare it with the standard three-trocar laparoscopic technique in terms of effectiveness, morbidity, and cosmesis. METHODS: Two matched groups of patients with left varicocele were recruited. Each group included 30 patients. One group underwent three-trocar and the other two-trocar laparoscopic varicocelectomy. The results of the two approaches were compared. RESULTS: No significant differences were found in terms of mean hospital stay or morbidity between the two-trocar and three-trocar techniques. A significant difference was found in the operative time and proportion of patients needing postoperative parenteral narcotic analgesia in favor of the two-trocar technique. In both approaches, the previously infertile patients had a significant improvement in sperm count and motility (P <0.05). Cosmetically, the trocar wound scars were aesthetically superior using the two-trocar technique. CONCLUSIONS: No significant difference was found between two-trocar and three-trocar laparoscopic varicocelectomy in terms of effectiveness and morbidity. The cost of an extra 5-mm disposable trocar in the three-trocar technique and the improved cosmesis after the two-trocar technique have made us prefer the latter technique.

Surgery or assisted reproduction? A decision analysis of treatment costs in male infertility.

PURPOSE: Assisted reproductive technology (ART), including in vitro fertilization and intracytoplasmic sperm injection, is routinely used to treat male factor infertility. Because of the success of ART, the optimal method to achieve pregnancy with male infertility is controversial. Two examples in which ART competes with traditional male infertility treatments are varicocelectomy and vasectomy reversal. We used formal decision analysis to estimate and compare the cost-effectiveness of surgical therapy and ART for varicocele and vasectomy reversal. MATERIALS AND METHODS: Decision analysis models were created for infertile men seeking paternity with varicocele and with post-vasectomy obstruction. Outcome probabilities applied to the model were derived from institutional and published sources. Costs of interventions were calculated from institutional data. Sensitivity analyses determined which elements were most important and, thus, were used to calculate threshold values. RESULTS: Vasectomy reversal is as cost-effective as ART if bilateral vasovasostomy can be performed. However, if unilateral or bilateral vasoepididymostomy is required, sperm retrieval/intracytoplasmic sperm injection may be more cost-effective due to lower patency rates. Vasectomy reversal is more cost-effective across all pregnancy rates provided that patency rates are greater than 79%. Surgical repair of varicocele is more cost-effective when the postoperative pregnancy rate is greater than 14% in men with a preoperative total motile sperm count of less than 10 million sperm and greater than 45% in men with greater than 10 million total motile sperm. CONCLUSIONS: A decision analysis based comparison of ART and classic surgical therapy suggests that varicocelectomy and vasectomy reversal are the most economical treatments in many cases of infertility due to these lesions. Tailoring the decision models to individual centers permits more accurate comparisons using specific costs as well as the surgical outcomes and results of ART.

Laparoscopic varicocele ligation: are there advantages compared with the microscopic subinguinal approach?

OBJECTIVES: To compare the operative time, outcome, complications, and patient costs between laparoscopic varicocele ligation (LVL) and subinguinal microscopic varicocelectomy (SMV) in two patient cohorts. Varicocele therapy is a controversial issue, with no single approach adopted as the best therapeutic option. LVL has been considered more expensive and of no proven benefit compared with SMV. METHODS: We compared two groups of patients who underwent surgical correction of varicocele at our institutions during a 6-year period. Group 1 included postpubertal adolescents who underwent LVL and group 2 included adults seen at an infertility practice who underwent SMV. The outcome measures selected included operative time, direct hospital costs to the patient, and negative outcomes. RESULTS: We identified a total of 72 patients, 36 (mean age 13.8 years) in group 1 and 36 (mean age 34.1 years) in group 2. Group 1 had no persistent or recurrent varicoceles compared with 4 patients in group 2. Three men in group 2 required emergency room evaluation and no patient did so in group 1. No hydroceles developed in group 2, but three developed in group 1. CONCLUSIONS: LVL resulted in shorter operative times and fewer negative outcomes compared with SMV. This translated into lower direct patient costs for LVL. For those who have mastered laparoscopic techniques, LVL should be considered a safe, cost-effective option in the correction of varicoceles.

The cost-effectiveness of treatment for varicocele related infertility.

PURPOSE: We compared the cost-effectiveness of 4 treatment strategies for varicocele related infertility from the perspective of the health care payor and patient. MATERIALS AND METHODS: Cost-effectiveness analysis was performed by studying 4 treatment strategies, namely observation, surgical varicocelectomy followed by in vitro fertilization (IVF) if unsuccessful, gonadotropin stimulated intrauterine insemination (IUI) followed by IVF if unsuccessful, and immediate IVF. The main outcome measure was incremental cost per live delivery of any number of newborns. RESULTS: Immediate IVF cost more per live delivery and was less effective than varicocelectomy/IVF or IUI/IVF. When electing the latter 2 procedures, the preferred approach depended on the choice of perspective. From the health care payor viewpoint each additional birth that resulted from choosing varicocelectomy/IVF over observation cost $52,152, while each additional birth that occurred by electing IUI/IVF over varicocelectomy/IVF cost $561,423. From the patient perspective, while varicocelectomy/IVF resulted in improved outcomes over observation, a rational decision maker would always be willing to pay the slightly higher cost of IUI/IVF (incremental cost per live birth versus observation $27,371) for the added benefit in effectiveness if they were initially willing to invest in varicocelectomy/IVF (incremental cost per live birth versus observation $27,618). CONCLUSIONS: The optimal choice of treatment for varicocele related infertility depends strongly on the decision maker perspective. Regardless of perspective the most technologically advanced treatment, that is immediate IVF, is never favored. The findings of this study should be used to counsel infertile patients with varicocele that immediate IVF is not cost-effective.

[Percutaneous, laparoscopic, and surgical treatment of idiopathic varicocele: analysis of costs]. / Il trattamento percutaneo, laparoscopico e chirurgico del varicocele idiopatico: analisi dei costi.

Idiopathic varicocele can compromise the spermatogenetic function of the testicle and associate with alterations of the semen quality. The treatment of varicocele stops the progress of testicular damage and improves spermatogenesis and semen parameters. These are the main alternatives to the traditional surgical treatment of varicocele retrograde percutaneous occlusion of the internal spermatic vein using sclerosing agents and embolizing devices (either separately or in combination), microsurgical ligation via inguinal or sub-inguinal approach, laparoscopic ligation and, more recently, antegrade scrotal sclerotherapy. None of these techniques can be considered the "gold standard" therapy. Literature does not point out any significant difference between them, either considering the absence of reflux percentage, or the improvement of semen quality, or the pregnance rate. Therefore cost comparison may be a valid criterion in the choice of treatment for varicocele correction. The total cost of the surgical retroperitoneal unilateral ligation of the internal spermatic vein is 968,805 Lire, while for the bilateral ligation it is 1,118,285 Lire. The costs of sclerotherapy and percutaneous embolization are respectively of 698,750 Lire and 1,708,950 Lire. The combination of the two techniques amounts to 1,918,230 Lire. Laparoscopic bilateral ligation costs 2,437,935 Lire. Antegrade scrotal sclerotherapy costs 191,035 Lire if unilateral, 216,580 Lire if bilateral. After considering these data we can say that antegrade scrotal sclerotherapy is the first choice economically in the treatment of both unilateral and bilateral varicocele.

Is assisted reproduction the optimal treatment for varicocele-associated male infertility? A cost-effectiveness analysis.

OBJECTIVES: To evaluate the cost-effectiveness of assisted reproduction using in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) as a primary treatment for varicocele-associated infertility. METHODS: Analysis of cost per delivery using published and contemporary results for treatment with ICSI in the United States for male factor infertility was compared with cost per delivery after surgical varicocelectomy. Only results from controlled trials of varicocelectomy were used for evaluation of pregnancy and delivery rates. Cost estimates were based on prevailing nationwide charges for services in 1994. RESULTS: The cost per delivery with ICSI was found to be $89,091 (95% confidence interval $78,720 to $99,462), whereas the cost per delivery after varicocelectomy was only $26,268 (95% confidence interval $19,138 to $44,656). Assuming the highest possible published success rate for ICSI resulted in a cost estimate as low as $62,263. The average published U.S. delivery rate after one attempt of ICSI was only 28%. whereas a 30% delivery rate was obtained after varicocelectomy. CONCLUSIONS: Specific treatment of varicocele-associated male factor infertility with surgical varicocelectomy is more cost-effective than primary treatment with assisted reproduction. Continued evaluation and treatment of the man with infertility is warranted. Despite the apparent success of ICSI for the most severe cases of male factor infertility, application of assisted reproduction for all cases of male factor infertility also does not necessarily provide as high a delivery rate as specific treatment of the cause of male factor infertility.

Financial analysis of antegrade scrotal sclerotherapy for men with varicoceles.

OBJECTIVE: To calculate and compare the costs of the treatment of varicocele by antegrade scrotal sclerotherapy with other modalities. PATIENTS AND METHODS: A total of 2305 operations using antegrade scrotal sclerotherapy to treat varicocele in childhood and adolescence were analysed for cost factors and compared with different surgical treatment methods for varicocele. RESULTS: Calculation of the pre-, intra- and post-operative costs showed that antegrade scrotal sclerotherapy was the most economically effective of all forms of surgical management for varicocele. CONCLUSIONS: Because antegrade scrotal sclerotherapy is a cost-effective treatment for varicocele, the indications for treatment may be widened to include more men with potential infertility, and thus avoid the need for expensive methods of artificial fertilization.

Clinical outcome and cost comparison of percutaneous embolization and surgical ligation of varicocele.

We reviewed the records of 81 consecutive subfertile men with oligospermia and/or asthenospermia, treated for varicocele with either percutaneous embolization or surgical ligation between 1987 and 1991, and compared the outcomes and costs of the two procedures. All men had presented with infertility of at least 6 months duration, and in most cases female factors had been previously evaluated and treated. Patients were offered a choice of embolization or ligation of the internal spermatic vein. Forty-five men (56%) underwent ligation, and 36 men (44%) opted for embolization. The mean age, serum follicle-stimulating hormone, pretreatment sperm density, motility, and concentration of motile sperm were similar for the two groups. Seminal quality improved in 65% of all patients after varicocele ablation (46 of 71). Improvements were seen in postoperative sperm density (P < 0.01), motility (P < 0.002), and concentration of motile sperm (P < 0.001). Thirty-nine percent of the assessable patients established pregnancies during the study interval (26 of 66). The two treatment groups did not differ significantly with regard to the likelihood of postoperative improvement in sperm density (P = 0.64), motility (P = 0.33), concentration of motile sperm (P = 0.11), or pregnancy rate (P = 0.83). Percutaneous embolization and surgical ligation of varicocele are equally effective in improving male infertility and cost about the same. Embolization offers the potential advantage of shorter recovery to full activity as compared to surgical ligation. Where experienced interventional radiologists are available, percutaneous embolization should be offered as an alternative to open ligation.