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viagra and cialis online control Level 2 60 infertile men with varicocele, 20 normozoospermic fertile men DFI and ROS levels decreased after varicocelectomy Clinical grades 1 3 Intervention inguinal varicocelectomy Lacerda et al 2011 364 Prospective study Comet DNA integrity, mitochondrial activity, and lipid peroxidation Improved sperm DNA integrity and mitochondrial activity Level 3 27 adolescents 15 19 years Comet class 1 cells undamaged DNA increased after repair Clinical grades 2 3 Intervention bilateral subinguinal micro varicocelectomy Zini and Dohle 2011 168 Systematic literature review 8- OHdG, TUNEL, Comet, SCSA, aniline blue SDF Most studies demonstrated higher SDF in varicocele patients, improved after varicocele repair Level 3 16 clinical articles included Clinical grades NA Intervention multiple approaches Zini et al 2005 367 Retrospective study AO, flow cytometry SDF Improved DNA damage after varicocele repair Level 3 37 men with varicocele Clinical grades clinical, subclinical, and no varicocele Intervention microsurgical varicocelectomy Smit et al 2013 178 Prospective study SCSA SDF Significant improvement in DFI post intervention Level 3 49 infertile men 37 conceived spontaneously Clinical grades 1 3 24 achieved with ART Intervention high inguinal or microsurgical sub inguinal Mean postoperation DFI significantly higher in couples who did not conceive Zini and Sigman 2009 268 Prospective trial SCSA SDF Sperm DFI improved 4 and 6- month post- intervention Level 3 25 infertile men with varicoceles Clinical grades NA Intervention microsurgical varicocelectomy Ghazi and Abdelfattah 2011 369 Prospective study TUNEL SDF SDF improved 6 months post intervention Level 3 81 infertile men with clinical varicocele Clinical grades NA Intervention microsurgical inguinal varicocelectomy Roque and Esteves 2018 177 Literature review Multiple SDF Men with varicocele have higher SDF Level 3 Clinical grades NA SDF decreases after varicocele repair Intervention multiple approaches Zaazaa et al 2018 370 Prospective cohort study SCD SDF Improved SDF after varicocelectomy with or without mast cell stabilizers Level 3 120 infertile men Clinical grades 2 3 Intervention microsurgical subinguinal varicocelectomy La Vignera et al 2012 371 Prospective study TUNEL SDF Control group showed lower SDF Level 3 30 men with varicocele and 30 fertile controls In varicocele patients, SDF was lower after varicocelectomy Clinical grade 3 Intervention microsurgical subinguinal varicocelectomy Kadioglu et al 2014 372 Retrospective study SCSA SDF Significant decrease in DFI post varicocelectomy Level 3 92 men with varicocele Clinical grades 1 3 Intervention microsurgical varicocelectomy Lara- Cerrillo et al 2020 373 Retrospective study Comet assay Single and double strand DNA breaks Significant decrease in the percentage of single and double DNA strand breaks after varicocelectomy Level 3 20 men with varicocele and 12 controls Clinical grades 1 3 Intervention microsurgical subinguinal varicocelectomy GarcГ­a- PeirГі et al 2014 374 Retrospective study TUNEL, SCD, SCSA SDF Infertile men with clinical and subclinical varicocele showed similar elevated SDF levels Level 3 15 untreated varicocele patients clinical grade 1, 16 with subclinical varicocele, 19 patients with surgically treated clinical varicocele, 10 with surgically treated subclinical varicocele and 21 fertile controls Only men with clinical varicocele showed improvement after varicocele repair Clinical grades clinical grade 1 and subclinical found on ultrasonography Intervention NA Cho et al 2016 375 Literature review SCD, SCSA, TUNEL Semen parameters Improved semen parameters, decreased SDF, increased pregnancy rates after clinical varicocele repair Level 3 Clinical grades clinical and subclinical varicocele SDF and pregnancy rate No benefit on fertility potential for repairing subclinical varicocele Intervention multiple approaches Baker et al 2013 263 Retrospective study TUNEL SDF SDF decreased post intervention Level 3 83 infertile men with varicocele 51 of couples were able to conceive naturally or with ART Clinical grades 1 3 Intervention microsurgical subinguinal varicocelectomy Tahamtan et al 2019 376 Retrospective study TUNEL SDF Men with varicocele had higher SDF than fertile controls Level 3 18 infertile men with clinical varicocele and 20 fertile controls Clinical grades 2 3 Intervention NA Wang et al 2012 176 Literature review and meta- analysis SCSA, TUNEL, Comet SDF Men with varicocele showed higher sperm DNA damage over controls Level 3 12 studies included in review Varicocelectomy can improve sperm DNA integrity Clinical grades 1 3 Intervention all surgical approaches considered Li et al 2012 377 Retrospective, case control series SCSA SDF DFI higher in varicocele group pre- intervention compared to controls and decreased at 3 months post- intervention, which was similar to levels for normal control group Level 3 19 infertile men with varicocele and 19 normozoospermic men Clinical grades 1 3 Intervention microsurgical subinguinal varicocelectomy Sakamoto et al 2008 378 Retrospective study TUNEL SDF TUNEL positivity significantly decreased after varicocele repair Level 3 28 azoospermic, 30 oligospermic 15 with varicocele, 30 normozoospermic 15 with varicocele Clinical grades 1 3 Intervention Microsurgical subinguinal varicocelectomy Telli et al 2015 380 Prospective study AO test SDF The mean DFI decreased after varicocelectomy Level 3 72 men with at least 1- year history of infertility, a palpable varicocele and oligospermia Sperm selection testicular sperm for ICSI Testicular sperm Arafa et al 2018 269 Prospective cohort study comparing testicular vs

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