**4. Spermiograms in the pediatric population**

Among the most important points to consider regarding varicocele in the pediatric population are the reliability of spermiograms, the ethical implications, and the

reliability of the results. The age at which men start producing spermatozoa; whether spermatogenesis and accessory gland secretions start on one certain day; and the time required for stabilization of the production, maturation, and the release of spermatozoa have not been clearly established. One of the problems encountered relates to the method used to obtain samples for semen analysis. The requirement that adolescents have to masturbate can cause a degree of conflict with the moral and ethical values of some sectors of society, although it has been pointed out that masturbation has no effect on health [5]. On the other hand, varicocele usually increases around adolescence and is rarely reported to occur later in adult men. Patients are commonly referred to a urologist either after detection of a scrotal mass, classically described as a "bag of worms", after detection of a difference in testicular size during childhood, or following a sport-related physical examination or for flank/ testicular pain even when in some cases they are completely asymptomatic. Kurtz et al. concluded that the total testis volume and the testicular volume differential are associated with semen analysis outcomes in adolescents with varicocele. A testicular volume differential greater than 20% doubles the odds of a low total motile sperm count. A total testis volume of less than 30 cc quadruples the odds of a low total motile sperm count [21].

A useful criterion could be that proposed by Dabaja (2014). The authors consider it is appropriate to request semen specimens by masturbation from teenagers at one year and six months after the onset of puberty. The age of puberty onset plus 1.5 years is an important predictor of ejaculation. Any adolescents around this age who have experienced ejaculation should be considered candidates for self-stimulation for the collection of a semen sample [22].

One of the first studies in this regard is that of Laron et al. [23].

The authors introduce the term "oigarche" as the age of first conscious ejaculation, in analogy with female menarche. Despite a wide range in the chronological age at the occurrence of the first conscious ejaculation, the mean bone age in all groups, including that with delayed puberty, was 13.5 ± 0.5 years (SD), ranging from 12.5 to 15.5 years.

An important observation regarding semen analysis is that proposed by Chu et al. The authors found that two-thirds of Tanner Stage V boys with uncorrected varicocele and normal testicular volumes achieve a normal total motile count irrespective of the varicocele grade or age. Despite Tanner stage V development, 47% of those with an initial "poor" SA will improve to normal status without surgery, and only a small subgroup of patients will have a persistently poor total motile count [24].

Therefore, some authors argue that the varicocele grade alone is not an indication for surgery in the majority of patients [14].
