4. Final considerations

for about 50% of all topics, and then diagnosis is still present, showing little differ-

Eventually, a study of the topics and their prevalence over years was performed to see the trend of interest. A significant trend in publications could not be evinced, neither overall nor for single continent. Publication numbers by year underwent cyclic changes over the last 20 years with a peak in 2008 including 16 publications

A natural comment to the number of publication is the fact that pediatric articles, focusing on pure research, account for <1 third of overall articles about varicocele. This could be due to the fact that historically varicocele is considered as an adult pathology; thus not enough interest is found in its pediatric side. Different series of studies report a higher prevalence of varicocele in adult population than in pediatric one. However it must be taken into account the lack, in almost all countries, of pediatric screening programs for varicocele that could give a strong bias about the exact prevalence of the pathology in pediatric population. Moreover the study of varicocele related to infertility is considered more imminent in adult life, when looking for paternity that during adolescence when study of future fertility may seem premature. In fact many studies on varicocele are performed retrospectively when

ence between main topic and all mentioned topics in the publications.

the patient in adult life has not the possibility to become father (see table).

rather a different contribution to publications.

varicocele.

64

language [10–17].

nents, the first interest of research is surgical technique, may it be traditional surgery or videolaparoscopy technique. We can also see that in the first three majorly represented topics and figures either screening or diagnosis this reflects an attention of research to detection and treatment rather than to follow-up or prevention of infertility. Other topics were only minimally represented. It must be stated that healthcare organization of each single country may influence the topics and publications: in fact screening would not be so represented in countries with private healthcare or, on the other hand, countries with increased population density would feel less important the problem of infertility. The prevalence of varicocele according to the literature remains constant in different ethnic groups; thus, differences in publication do not reflect a difference of entity of the disease but

Concerning the major topics of the publications, in the most represented conti-

In South America the research group for the published articles is the same, and

The three most prevalent topics in North America and Asia underline an attention to study the evolution of the pathology in time even after treatment and to evaluate if the outcomes of surgical treatment meet the standards for good practice. Articles discussing endocrinology often evaluate testicular volume at diagnosis and follow catch-up growth after surgery, trying to give an indication of the best timing to prevent infertility. On the other side, the spectrum of topics in Europe reflects

Of particular interest is that there is no increasing trend during the years despite

the works represent mainly an evolution of the same study focusing on semen analysis, metabolomics, infertility pathophysiology, and endocrinology.

poor attention to prevention of infertility and follow-up after surgery.

an increase in the trend of publications about overall causes of infertility and medically assisted procreation. In fact in delivering a PubMed research, it appears that publications about MAP are more than 30 times higher than those about

We must report the fact that Asia appears abundantly below average, but a strong bias is given that the fact that many publications from China were in original

The same applies to the correlation between undescended testes and infertility if compared to the studies on cryptorchidism alone. Both associations between infertility and disease show a progressive percentage increase in the total number of studies.

about pediatric varicocele.

Male Reproductive Health

This research is intended as a warning to the countries worldwide: when talking about fertility, it is right to give a couple the chance to access medically assisted procreation; consequently, scientific studies to improve its outcomes are reasonable. International reports are therefore necessary and should foster research with increasing outcomes. More space should also be given to investigate and prevent male fertility diseases starting from the pediatric age, especially when they might impair the patient's future fertile potential [18].

All those involved in the pediatric treatment area should be stimulated to act toward this goal, and each country should bear the responsibility of promoting and financing andrological screening campaigns. At the international level, there are still few opportunities, in terms of funds and staff, for the adolescents to receive andrological counseling. This is then the bottom line: Is medically assisted procreation the cure to one or more diseases, or is it the answer to the lack of a social support network?

When talking about couple infertility, male causes account for about 35–40%, among these, varicocele figures as the first [19].

Thus collective interest, research efforts, and healthcare funding aim to study couple infertility at the time of inability of procreation, correction of varicocele in adult age, and medically assisted procreation. This choice is taken despite the increased risk of chronic irreversible damage of treating varicocele and other pediatric andrological diseases in adult age and despite the costs and risks of MAP with the additional risk of failure of medically assisted procreation.

In conclusion, the research effort and the capital invested in prevention of infertility are not balanced with respect to efforts and investments relied into medical assisted procreation.

### Conflict of interest

The authors declare no conflict of interest.

### Acronyms and abbreviations


ART Assisted reproductive technology

Male Reproductive Health
